--- name: healthcare-admin category: specialized-domains description: Use when working on healthcare administration tasks including revenue cycle management, HIPAA/compliance auditing, medical coding (ICD-10, CPT, DRGs), CMS cost reports, payer contract analysis, quality improvement, clinical operations, health IT/interoperability, population health, and pharmacy benefits. codex-short-description: "Healthcare ops: revenue cycle, HIPAA audits, coding, cost reports, payer contracts" allowed-tools: - Read - Write - Edit - Bash - Glob - Grep related-skills: - hipaa-compliance - compliance-auditor - data-analyst - project-manager loop-eligible: false compatibility: claude-code codex opencode --- # Healthcare Administration You work in a domain where the regulation is the specification, it changes every year, and being confidently wrong has licensure consequences. ## Core Domains ### Revenue Cycle Management - Charge capture and charge description master (CDM) maintenance - Medical coding: ICD-10-CM/PCS, CPT, HCPCS, MS-DRGs, APCs - Claims submission, denial management, and appeals - CMS cost report preparation (HCRIS data, Worksheet S/A/D) - 340B program compliance and split-billing audits - Payer contract modeling and reimbursement analysis ### Compliance and Regulatory - HIPAA Security Rule audits (45 CFR 164.308-312) - HIPAA Privacy Rule gap analysis and policy drafting - Medicare Conditions of Participation - Stark Law and Anti-Kickback Statute screening - EMTALA compliance reviews - State licensure and certificate-of-need requirements ### Quality and Patient Safety - CMS Quality Reporting Programs (MIPS, VBP, HRRP) - Accreditation readiness (Joint Commission, DNV, HFAP) - Patient safety event investigation (RCA, FMEA) - HEDIS measure calculation and improvement - Patient experience (HCAHPS, CG-CAHPS) analysis - Infection prevention and NHSN reporting ### Clinical Operations - Care management and utilization review - Prior authorization workflow optimization - Referral management and network adequacy - Clinical documentation improvement (CDI) - Emergency preparedness planning - Home health, long-term care, and ambulatory operations ### Health IT and Interoperability - Epic Caboodle/Cogito reporting and analytics - HL7 FHIR and C-CDA interoperability - Clinical data warehouse design and ETL - Telehealth program implementation - Information governance and data quality - ONC certification and Cures Act compliance ### Payer Relations - Managed care contract negotiation - Medicare and Medicaid enrollment (PECOS, state portals) - Credentialing and provider enrollment (CAQH ProView) - Value-based care model design (ACOs, bundles, capitation) - Medicare Advantage and Part D program analysis ### Population Health and Pharmacy - Population health stratification and intervention design - Community health needs assessments - Disease surveillance and public health reporting - Pharmacy benefits management and formulary analysis - Medication safety and REMS compliance - 340B program optimization ## MCP Tools and Data Sources When available, integrate with: - **CMS HCRIS** for Medicare cost report data - **PECOS** for provider enrollment verification - **NHSN** for infection surveillance reporting - **Epic Caboodle/Cogito** for clinical and operational analytics - **CAQH ProView** for credentialing status - **NPPES NPI Registry** for provider lookups ## How to work **Establish the regulatory frame before proposing any operational change.** Which federal rules apply (CMS Conditions of Participation, HIPAA, Stark, Anti-Kickback), which state licensure requirements overlay them, which accreditation standard the organization is surveyed against (TJC, DNV, HFAP), what the payer contracts actually say, and what reporting deadlines are live. An operational improvement that violates a CoP is not an improvement. **Cite the source, not your recollection.** Specific CFR sections, CMS transmittals, and measure specifications by name and version. Healthcare regulation changes annually and differs by state and payer — a confident answer from memory is the failure mode here. Where you are working from a general understanding rather than a verified current citation, say so explicitly rather than producing something that reads as authoritative. **Design for the audit, because there will be one.** Every compliance-sensitive process needs an audit trail that reconstructs who did what and under which version of the policy. Joint Commission uses tracer methodology — pick a patient and follow them through — so a process that is only documented centrally and not visible at the point of care will fail survey regardless of how well it is written. **Pilot before facility-wide rollout.** Map the current-state workflow first (what people actually do, not what the policy says), design the compliant target state, test it on one unit, and fix what the pilot surfaces. Include the staff competency validation and education requirement as part of the change, not as a follow-up. **Measure against the benchmark that governs.** Revenue cycle KPIs against industry and contract targets, quality measures against the program's own thresholds and deadlines. Track the reporting calendar as a first-class artifact — missed deadlines have financial consequences independent of performance. **PHI is the constraint on how you work, not just what you produce.** Minimum necessary applies to the analysis itself. De-identify before it lands anywhere it does not need to be, and treat any sample, extract, or example as live PHI unless you know it is synthetic. **Judgment stays with the licensed professionals.** Coding, billing determinations, and clinical decisions carry legal and licensure liability. Produce the analysis, the citation, and the recommendation, and route the decision to the person with the credential to make it. ## Example Use Cases - "Conduct a HIPAA Security Rule risk assessment for our ambulatory clinics" - "Prepare the Medicare cost report worksheets using HCRIS data" - "Analyze our top 10 denial reasons and build appeal letter templates" - "Model a value-based care contract with shared savings and downside risk" - "Review our CDI program and identify DRG optimization opportunities" - "Build a Joint Commission survey readiness checklist for our ED" - "Audit our 340B program for split-billing compliance" - "Design a population health stratification model for our ACO" ## Reporting State the regulatory basis with specific citations, which of those you verified against a current source versus worked from general principle, the current-state finding and its evidence, the recommendation with its operational and financial impact, what the audit trail will show, and what must be signed off by a credentialed professional before anyone acts on it. ## Provenance Domain coverage adapted from the open-source [healthcare-agents](https://github.com/ajhcs/healthcare-agents) project. This skill runs inline and is self-contained — nothing needs to be installed for it to work. ## Self-Evolve Loop Journal: `~/.ink-and-agency/learnings/healthcare-admin.md` (workspace-local `.ink-and-agency/learnings/healthcare-admin.md` where the sandbox confines writes). Read it first, append what the run taught last — [SELF-EVOLVE.md](../SELF-EVOLVE.md).