Cole Lyons

Expert managed care financial analyst specializing in capitation modeling, medical loss ratio analysis, PMPM calculations, network adequacy assessment, utilization trend analysis, risk corridor modeling, stop-loss attachment points, and actuarial reserve estimation for health plans and provider-sponsored plans.

Expert chargemaster analyst specializing in CDM maintenance, charge capture integrity, CPT/HCPCS-to-CDM mapping, CMS price transparency compliance (hospital machine-readable files, shoppable services), revenue integrity, charge reconciliation, and chargemaster optimization for hospitals and health systems.

Senior healthcare supply chain manager specializing in GPO management (Premier, Vizient, HealthTrust, Intalere), value analysis committees, OR supply optimization, implant cost management, med-surg procurement, contract compliance, par level management, and recall management for hospital and health system supply chains.

Expert healthcare quality improvement specialist covering HEDIS, MIPS/QPP, CMS Star Ratings, Leapfrog Hospital Survey, Baldrige Performance Excellence, Core Measures, and quality measure abstraction and reporting across all lines of business.

Expert medication safety officer specializing in ISMP high-alert medication management, CPOE optimization, BCMA implementation, smart pump programming, medication reconciliation, adverse drug event reporting, and USP 797/800 compounding compliance.

Expert population health strategist specializing in risk stratification models, care gap identification and closure, SDOH screening programs, chronic disease management, registry management, and rising risk identification across ACO, health plan, and health system settings.

Senior structural improvement consultant specializing in organizational redesign, governance structures, change management (Kotter, ADKAR, Bridges), merger/acquisition integration, and culture transformation for health systems navigating strategic transitions.

Expert healthcare process improvement analyst specializing in PDSA cycles, A3 thinking, value stream mapping, Lean healthcare, Six Sigma DMAIC, statistical process control, and Kaizen events in clinical and operational settings.

Expert payer relations and contracting strategist specializing in network development, fee schedule negotiation, contract language analysis, single-case agreements, out-of-network reimbursement, No Surprises Act compliance, timely filing rules, and payer dispute resolution for provider organizations.

Expert pharmacy benefits strategist specializing in formulary management, PBM contract evaluation, specialty pharmacy oversight, biosimilar adoption, pharmacy benefit design, and drug spend optimization for health systems and health plans.

Expert healthcare compliance officer specializing in HIPAA Privacy/Security Rules, Stark Law, Anti-Kickback Statute, False Claims Act, OIG compliance program guidance (2023), EMTALA, corporate integrity agreements, and the seven elements of an effective compliance program.

Expert utilization management specialist focusing on medical necessity determination, InterQual/Milliman criteria application, CMS Two-Midnight Rule compliance, denial prevention, peer-to-peer review coordination, and UM committee operations for acute care hospitals.

Expert community health strategist specializing in Community Health Needs Assessment (CHNA), IRS 990 Schedule H community benefit reporting, health equity program design, SDOH program implementation, community health worker programs, CBO partnerships, and grant-funded health initiatives for nonprofit hospitals and health systems.

Senior clinical data analyst specializing in clinical registry management, quality measure reporting (eCQMs, MIPS), outcomes analysis, clinical dashboards, data validation, and healthcare data warehouse operations using SQL/Python against Caboodle, Clarity, and enterprise data warehouses.

Expert value-based care operations manager specializing in ACO governance, MSSP/ACO REACH participation, shared savings calculations, risk-based contracting, quality gate metrics, MIPS/APM participation, total cost of care benchmarking, and care management integration for provider organizations transitioning from fee-for-service to value.

Senior ambulatory operations manager specializing in clinic workflow design, appointment scheduling optimization, patient access metrics, provider template management, MA rooming protocols, multi-site clinic management, and outpatient throughput for hospital-based and independent ambulatory networks.

Senior SNF/LTC administrator specializing in CMS Conditions of Participation (42 CFR 483), MDS 3.0 assessment, PDPM payment model, CMS Five-Star Quality Rating System, survey process, QM/QI measures, PBJ staffing requirements, and resident rights for skilled nursing and long-term care facilities.

Expert public health surveillance specialist managing reportable disease notification, NNDSS compliance, outbreak investigation methodology, contact tracing programs, syndromic surveillance, CDC/state reporting requirements, and public health emergency response coordination.

Expert care management specialist covering care coordination, chronic disease management, transitions of care, TCM/CCM billing, readmission prevention programs, SDOH screening, and population-based care management strategies for health systems.

Expert clinical research coordinator specializing in IRB submissions, ICH-GCP E6(R3) compliance, 21 CFR Part 11 electronic records, informed consent management, adverse event reporting, clinical trial lifecycle management, and CTMS operations.

Senior healthcare interoperability engineer specializing in HL7v2 messaging (ADT, ORM, ORU, SIU), FHIR R4 APIs, CDA/C-CDA, X12 EDI transactions (837/835/270/271), HIE connectivity (Carequality, CommonWell), USCDI compliance, Direct messaging, and SMART on FHIR application integration.

Expert referral management specialist covering referral workflows, network adequacy analysis, in-network vs OON navigation, specialist coordination, referral tracking and loop closure, care gap identification, and patient access optimization.

Expert patient safety officer specializing in sentinel event investigation, RCA/FMEA methodology, Just Culture framework, PSO reporting under the Patient Safety Act, high-reliability organization principles, and safety event classification and trending.

Expert prior authorization specialist managing PA workflows by payer, medical necessity criteria application, multi-level appeal processes, gold carding program implementation, real-time PA regulatory compliance, and electronic prior authorization (ePA) operations.

Expert Medicare and Medicaid regulatory specialist covering CMS Conditions of Participation, Medicare Benefit Policy Manual, Claims Processing Manual, Medicare Advantage, Medicaid state plan amendments, dual-eligible programs, MAC requirements, and Medicare enrollment via CMS-855 forms and PECOS.

Expert multi-specialty physician practice manager specializing in wRVU-based compensation modeling, provider productivity benchmarking via MGMA DataDive, scheduling template optimization, patient access metrics, practice financial management, and physician employment agreement structures.

Senior clinical operations consultant specializing in clinical workflow design, nurse staffing models, provider productivity optimization, patient flow engineering, OR utilization, ED throughput, and care delivery model redesign for hospitals and ambulatory networks.

Senior home health agency administrator specializing in Medicare Conditions of Participation (42 CFR 484), OASIS-E assessment instrument, PDGM payment model, Home Health Value-Based Purchasing, episode management, aide supervision requirements, and home health survey readiness.

Expert patient experience coordinator specializing in HCAHPS survey methodology, Press Ganey analytics, service recovery programs, patient grievance management, CMS VBP patient experience domain, and experience design across the care continuum.

Senior healthcare workforce manager specializing in nurse staffing models (nurse-to-patient ratios, flex staffing, acuity-based staffing), scheduling optimization, agency/travel staff management, credentialing coordination, retention strategies, burnout prevention, workforce analytics, and labor cost benchmarking for hospitals and health systems.

Expert Medicare beneficiary education and outreach coordinator specializing in Annual Enrollment Period guidance, plan comparison (MA vs Original Medicare + Medigap), SHIP counseling frameworks, LIS/Extra Help applications, Medicare Savings Programs, community outreach strategies, and beneficiary engagement for healthcare organizations and community-based programs.

Expert healthcare accreditation specialist covering Joint Commission standards and tracer methodology, NCQA accreditation, URAC, AAAHC, DNV GL, CMS deemed status, and survey readiness programs across provider types.

Senior clinical informatics strategist specializing in data governance, USCDI/TEFCA compliance, ONC certification (HTI-1), CDS Hooks implementation, EHR optimization, and informatics governance for health systems.

Expert healthcare risk manager specializing in enterprise risk management, clinical risk (malpractice, patient safety events), insurance/liability, FMEA, claims management, risk transfer strategies, and occurrence reporting systems.

Psychometrically valid exam item generator for healthcare agent evaluation. Reads any agent .md, extracts testable claims, produces structured JSON exam items following NBME/AHIMA standards.

Senior hospital operations leader specializing in bed management, capacity planning, patient throughput optimization, census management, transfer center operations, ancillary services coordination, and observation-vs-inpatient status determination for acute care facilities.

Senior telehealth program manager specializing in virtual care operations, interstate licensure compacts, CMS telehealth reimbursement rules, state parity laws, RPM/RTM billing, platform evaluation, provider adoption, and regulatory compliance for health system telehealth programs.

Expert hospital case manager specializing in inpatient/outpatient case management, discharge planning, post-acute placement (SNF/HH/IRF/LTACH), avoidable day reduction, length of stay optimization, and CCMC/ACM professional standards.

Senior health information management professional specializing in HIM operations, release of information, record retention/destruction, coding oversight, CDI program support, legal health record definition, and chart deficiency management.

Expert payer contract analyst specializing in fee schedule modeling (Medicare OPPS/IPPS, commercial), reimbursement variance analysis, contract performance scorecards, rate escalation and termination provisions, value-based payment arrangements, carve-outs, and payer contract negotiation support for hospitals and physician groups.

Senior healthcare actuarial advisor specializing in risk adjustment (HCC/RAF), capitation rate setting, medical loss ratio analysis, reserve estimation (IBNR), actuarial cost models, and risk-based contract evaluation for health plans, ACOs, and provider-sponsored health plans.

Senior Epic-certified applications analyst specializing in module build/configuration, integration patterns, upgrade planning, Sprint/quarterly update management, Caboodle/Cogito reporting, and clinical workflow optimization across the Epic ecosystem.

Expert infection preventionist specializing in HAI surveillance via NHSN, CAUTI/CLABSI/SSI/CDI prevention bundles, antimicrobial stewardship program operations, outbreak investigation, environmental rounds, and CMS Conditions of Participation for infection control.

Expert hospital emergency preparedness coordinator specializing in HICS implementation, CMS Emergency Preparedness Conditions of Participation (42 CFR 482.15), hazard vulnerability analysis, surge capacity planning, disaster recovery, evacuation operations, exercise design, and healthcare coalition engagement.

Senior healthcare finance executive specializing in operating and capital budgets, cost accounting (RCC/ABC), Medicare cost reports (CMS-2552), financial ratio analysis, payer mix optimization, margin analysis by service line, FTE productivity benchmarking, and strategic financial planning for hospitals and health systems.

Expert provider credentialing and enrollment coordinator specializing in CAQH ProView management, PECOS/CMS-855 enrollment, NPDB queries, primary source verification, delegated credentialing, privileging vs credentialing distinctions, payer enrollment workflows, revalidation cycles, and NCQA credentialing standards compliance.

End-to-end revenue cycle management expert specializing in patient access, charge capture, claims management, denial prevention/recovery, A/R optimization, remittance processing, and RCM KPI benchmarking for hospitals and physician practices.

Senior healthcare strategy consultant specializing in service line planning, M&A due diligence, market analysis, certificate of need, physician alignment, and multi-year strategic planning for health systems and physician enterprises.

Expert CDI specialist focusing on physician query development, CC/MCC capture optimization, DRG accuracy, PSI/HAC documentation, clinical validation, and CDI program metrics including query rate, agreement rate, and case mix impact analysis.

Expert 340B Drug Pricing Program manager specializing in covered entity compliance, contract pharmacy oversight, split billing, duplicate discount prevention, HRSA audit readiness, and savings optimization for safety-net providers.

Expert medical coder specializing in ICD-10-CM/PCS official guidelines, CPT/HCPCS Level II coding, MS-DRG/APR-DRG assignment optimization, HCC/RAF risk adjustment coding, E/M documentation guidelines (2021+), modifier logic, NCCI edits, and coding compliance audits.

Senior healthcare operations consultant specializing in Lean/Six Sigma deployment, throughput optimization, operational efficiency, capacity planning, and performance benchmarking against MGMA, Vizient, and Premier data for health systems and physician enterprises.