James Rose
Managing Director
Healthcare Compliance Practice Leader, Corporate Compliance, Litigation Disputes
CPA, CIA, CRMA, CISA, CISSP, CHC
Career Highlights
- Licensed Certified Public Accountant (CPA) (#7498)
- Certification in Risk Management Assurance (CRMA)
- Certified Information Systems Auditor (CISA)
- Certified Information Systems Security Professional (CISSP)
- Certified Internal Auditor (CIA)
- Managed Healthcare Professional (AHIP)
- Certified in Healthcare Compliance (CHC) (2015-2017)
- Predictive Index Analyst (2008)
- Certified RSA Archer Professional (2010)
James Rose is Managing Director of SunHawk Consulting LLC. Mr. Rose is a CPA and holds certifications in Internal Auditing (CIA), Risk Management Assurance (CRMA), Information Systems Auditing (CISA, CISSP), and Healthcare Compliance (CHC). James is an experienced healthcare operations, governance, risk, and compliance executive focused on the healthcare and governmental industries. He currently serves as an expert advisor to the World Health Organization’s Staff Health Insurance Global Oversight Committee (providing his expertise on health and wellness programs as well as medical insurance cost management and financial planning). Mr. Rose is also Chair of the Jefferson County Public Schools Audit and Risk Advisory Committee.
In the private sector, he served as Chief Financial Officer of Aperture Credentialing LLC, where he was also accountable for many of the traditional Chief Operating Officer duties in addition to CFO / Controller responsibilities. Mr. Rose also served as Director with Navigant’s Healthcare and Life Sciences Disputes, Regulatory, Compliance and Investigations practice – serving as the payer sector practice leader. Prior to Navigant Mr. Rose was Vice President & Chief Auditor at Humana – a Fortune 100 organization – for 15 years, most recently where he served as the Chief Audit Officer and Risk Leader helping to establish the organization’s ERM program and GRC technology platform.
In the public sector, Mr. Rose held audit and consulting roles in the federal government as a Foreign Service Officer with the Office of the Inspector General of the U.S. Agency for International Development and as Director of Financial and Performance Audit for the State of Kentucky. Mr. Rose served for eight years as a member of the Audit Committee of the $5 billion United Nations World Food Programme in Rome, the last few years serving as Chair. Mr. Rose also served as co-lead of the Data Analysis Committee of the Healthcare Fraud Prevention Partnership, a joint effort of the U.S. Department of Health and Human Services and the U.S. Department of Justice.
With the Institute of Internal Auditors, James is currently serving the International Standards Board for the global profession. He has published several pieces of Institute guidance on root cause analysis, maturity models, assessments of the control environment, and global competencies of the profession. With the Health Care Compliance Association (HCCA) and Society of Corporate Compliance and Ethics (SCCE) he is a regular speaker and serves on the faculty of the Compliance Auditing and Monitoring Workshops.
Select Engagement Experience
Review of Claims for a Large Dental Organization
A large multi-practice dental organization engaged SunHawk to perform a random sample review of claims on a quarterly basis, ensuring that documentation and billing met requirements. Based on SunHawk’s review, we provided recommendations for internal practice and medical documentation, aiming to clearly substantiate that procedures were performed. Over the year-long project, the practice group initiated several small yet significant changes, which led to a decrease in the frequency of coding errors and improvements in clear, supportive documentation.
Behavioral Health Organization Evaluation for a New EHR System
SunHawk partnered with a large, multi-faceted behavioral health organization to evaluate their current procedures, documentation, and coding as they sought a new electronic health record (EHR) system. Through staff interviews, site visits, and facility tours, SunHawk identified limitations of the existing EHR system and understood the process flow from patient intake to discharge. They distinguished necessary tasks from desirable ones in a new EHR system, which helped to eliminate or reduce the current limitations. This led to a tailored requirement list for a new EHR system, which the entity presented to prospective vendors for a customized solution.
Medical Coding Audit and Clinical Documentation Improvement Related to Acquisition
SunHawk Consulting was entrusted by a multi-state population health management company to carry out a comprehensive audit of documentation for telehealth visits. This audit was necessitated as part of the strategic acquisition of a California-based health plan that was utilizing telehealth services for its members. Throughout the auditing process, SunHawk employed its expertise to unearth critical insights and identify necessary modifications to the existing documentation templates as clinical documentation improvements to ensure documentation supported all requirements of a telehealth visit.
Clinical Documentation Improvement and Medical Coding Audit on Annual Wellness Visits
SunHawk Consulting was hired by a multi-state population health management to carry out a comprehensive audit of medical record documentation of encounters which had been billed as a Medicare Annual Wellness Visit (AWV). This audit was necessitated as part of the strategic acquisition of a California-based health plan that was utilizing telehealth services for the AWV for its members. SunHawk identified missing and/or inadequate documentation, calculated the resulting Medicare overpayment, and formulated a comprehensive list of proposed changes for provider education and the existing documentation templates for clinical documentation improvement purposes.
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SunHawk Consulting
2550 E Rose Garden Ln.
Unit 72016
Phoenix, AZ 85050
[email protected]
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