Clinical Coding Audit Director
RN, CPC, CRC, AHCCA, HCAFA
Career Highlights
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- Registered Nurse (40+ years)
- Presented FWA investigation findings at CMS conference
- Testified as Expert Witness in both Civil and Criminal Court Cases
- Established the Medicare Advantage Part C FWA review process for the MEDIC
- Certified Professional Coder (CPC)
- Certified Risk Adjustment Coder (CRC)
- Advanced HCC Auditor (AHCCA)
- HealthCare Anti-Fraud Associate (HCAFA)
Lorraine Aniello
Coding Audit Practice Leader, Healthcare Compliance, Litigation Disputes
Lorraine is a Registered Nurse and holds certification as a Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC) from the American Academy of Professional Coders (AAPC), and Advanced HCC Auditor (AHCCA) from Rise Health. She is also certified as a HealthCare Anti-Fraud Associate (HCAFA).
Lorraine has been a coding trainer and reviewer for one of the largest U.S. healthcare organizations. Within regulatory organizations, she has worked with state Medicaid policy and program integrity, MFCUs, RACs, MEDIC, and was a corporate clinical trainer for a national vendor who assisted Medicare and Medicaid Advantage companies with risk adjustment data collection, coding and reporting. She has provided testimony and expert analysis for both government prosecutors, litigation counsel, and defense counsel.
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.
Testimonials
"SunHawk was an outstanding partner in the provision of interim leadership in compliance and internal audit for our organization. They provided seamless coverage and advancement of our compliance and internal audit functions. As CEO, I had no concerns or worries during our engagement. They were true partners for us!"
Alfred E. Pilong
President and CEO
Garnet Health
"James and the SunHawk team have been an invaluable resource for our Compliance Office - they are a reliable, well experienced, trusted and knowledgeable team of professionals who at a moment’s notice will take your calls or respond to your emails.
Their advice helped us navigate the ever evolving, highly regulated healthcare industry! Whether it’s discussing report methodology or determining appropriate repayment, SunHawk provides the reassurance and confidence that you are doing the right thing!
We are honored to have partnered with SunHawk and will continue to do so in the future!"
Natasha Cogdill
Vice President/Chief Ethics, Compliance and Privacy Officer
Community Health System
"SunHawk’s professionals are leaders in the compliance and risk industries. Over the years I have worked with a number of their professionals on a series of projects/issues and learned SunHawk’s professionals are problem/solution-oriented and great coalition builders.
SunHawk Professionals get the job done and are a pleasure to work with. Commitment, Experience, Professionalism, and Integrity; that's what SunHawk Professionals brings to the table."
Gerry Roy
Vice President/Chief Ethics, Compliance and Privacy Officer
Phoenix Children's Hospital
"Jim Rough is among the most conscientious professionals I have encountered. When he says he is going to do something -- he does it. Jim has a broad range of experience gained over decades in leading organizations.
Now as the founder of his own firm, Jim will be enabled to provide the same high-quality service to his clients in a setting that allows greater customization to his clients' financial circumstances."
Frank M. Placenti
Chair, US Corporate Governance & Securities Regulation
Practice, Squire Patton Boggs
"SunHawk Consulting's HIPAA Check Program provided us with an invaluable third-party review of our HIPAA policies and practices. The tracking tool SunHawk includes with the Program has become an integral part of our continued monitoring for HIPAA compliance.
Jan Elezian's extensive hands-on compliance experience was evident during site visits and staff interviews as she translated difficult subject matter into practical use scenarios and provided quality feedback. Thank you SunHawk team!"
Nancy Lipman
Vice President, Compliance
Chicanos Por La Causa, Inc.
"SunHawk provides an array of dynamic professionals, each with significant subject matter expertise and a problem-solver approach. Beyond their knowledge and conscientious work ethic, however, is a team of caring individuals who strive to furnish individualized, tailored assistance with a personal touch.
Jim Rough's dedication to the success of SunHawk clients is evidenced by his strategic and prospective thinking complemented by his ability to truly anticipate the needs of a company in the midst of the complicated compliance climate. I highly recommend SunHawk for companies of any size seeking actionable solutions and measurable results."
Michelle Missal
Vice President and Chief Compliance Officer
Paragon 28, Inc.
Get In Touch
SunHawk Consulting
2550 E Rose Garden Ln.
Unit 72016
Phoenix, AZ 85050
info@sunhawkconsulting.com
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SunHawk Consulting specializes in professional consulting services and has a team of highly skilled subject matter experts with substantial backgrounds in:
* Healthcare Compliance: statistical sampling & coding audit services, design and implementation of healthcare compliance programs, evaluation of compliance programs and risk assessments, HIPAA compliance risk assessments & training, corporate integrity agreement (CIA) board advisor, independent review organization (IRO) services, interim healthcare compliance support, physical security assessment;
* Corporate Investigations: fraud investigations and forensic accounting, anti-money laundering (AML), bank secrecy act (BSA), know your customer (KYC), foreign corrupt practices act, third-party due diligence;
* Corporate Compliance: Evaluation and Design of Corporate Compliance Programs, Interim Compliance Support, Compliance Risk Assessments, Physical Security Assessment, Enterprise Risk Management, Private Equity Governance, GRC System Support, Audit Function Support, Fraud Risk Assessments, Investigations Program Assessment and Enhancements, Qui Tam Investigations, Hot Line Support;
* Litigation Disputes: Complex Litigation and Disputes, Mergers and Acquisitions: Regulatory Due Diligence, Expert Witness, Statistical Analysis, Healthcare Payment Disputes, Litigation Support, Physical Security Assessment, and Neutral Party Data Analysis.