Healthcare Services

Health-plan Platform Modernization

Offer implementation, integration, upgrades and production support for:

• Cognizant TriZetto FACETS
• HealthEdge HealthRules
• QNXT
• Epic Tapestry
• Salesforce Health Cloud
• Medicare and Medicaid administration platforms

Include claims configuration, benefits, enrollment, provider contracts, accumulators, billing and encounter processing.

Medicaid Enterprise Systems

Your EHS and Medicaid experience can become a dedicated practice covering:

• MMIS modernization
• Medicaid eligibility and enrollment
• Provider enrollment
• Claims and encounter processing
• Managed-care integrations
• Program integrity and fraud analytics
• Independent Verification and Validation
• CMS certification support
• Data conversion and system testing

Interoperability and Prior-Authorization Automation

Build services around:

• HL7 and FHIR integration
• Provider-access APIs
• Patient-access APIs
• Payer-to-payer data exchange
• Electronic prior authorization
• EDI transactions such as 270/271, 276/277, 278, 834, 835 and 837
• HIE and laboratory interfaces

This is a growing area because healthcare organizations must connect older claims and clinical systems with modern APIs.

Healthcare Data, Analytics and AI

Possible offerings include:

• Claims and clinical-data platforms
• Risk-adjustment analytics
• Fraud, waste and abuse detection
• Readmission and utilization analysis
• Provider-performance dashboards
• Automated claims-document classification
• AI-assisted member-service applications
• Prior-authorization document summarization
• Generative-AI knowledge assistants for employees

AI recommendations affecting coverage or patient care should retain human review, audit trails, access controls and data-governance procedures.

Healthcare Cybersecurity

Healthcare organizations urgently need:

• HIPAA security-risk assessments
• Identity and access management
• Multifactor authentication
• Vulnerability scanning and remediation
• Security monitoring
• Ransomware preparedness
• Incident-response planning
• Third-party vendor assessments
• Backup and disaster-recovery testing

HHS identifies vulnerability management, endpoint protection, email security and MFA among its healthcare cybersecurity performance goals.

HIPAA Responsibilities

If Sharpedge creates, receives, stores or transmits protected health information for a customer, it may become a HIPAA business associate. That can require:

• A Business Associate Agreement
• HIPAA privacy and security policies
• Workforce training
• Access controls and audit logging
• Risk assessments
• Encryption and secure data disposal
• Breach-response procedures
• Controls over subcontractors

HHS states that business associates must apply appropriate administrative, physical and technical safeguards to electronic protected health information.

Colorado Direct-Care Staffing Compliance

For Colorado assignments involving services to at-risk adults, Sharpedge Solutions follows applicable candidate-screening and credential-verification requirements.

“Direct care” includes case management, protective services, physical care, mental-health services, and other services necessary for an at-risk adult’s health, safety, or welfare, as defined in C.R.S. § 26-3.1-101(3.5).

When required for a position or client facility, candidates must successfully complete applicable criminal-background, professional-license, exclusion-list, and Colorado Adult Protective Services Data System checks before beginning the assignment. Screening requirements may vary according to the position, facility type, client agreement, and applicable Colorado law.

Review the Colorado statutory definition of direct care