Redesigning Finance from the Inside Out with Sham Firdausi

Public health safety net systems are absorbing some of the most severe financial pressure in recent memory, and the finance leaders running them face a challenge that goes well beyond budgeting. Sham Firdausi, Deputy Chief Financial Officer of the County of Santa Clara Health System, is eight months into a role that requires him to simultaneously navigate a projected shortfall approaching $1 billion, modernize a finance function built for a different era, and protect care for every patient who walks through the door regardless of ability to pay.

Firdausi spoke with James Leuthe, CEO of Scopewell Solutions, about the structural choices he is making and the philosophy behind them.

An unconventional path to the CFO suite

Most finance chiefs at large health systems arrive through accounting and corporate finance. Firdausi's route ran through the U.S. Marines, the Army's 101st Airborne Division, a deployment to Iraq, and then a deliberate effort to learn every layer of the American healthcare system after being injured in service.

He joined the Optum side of UnitedHealth Group to learn revenue cycle operations from the inside, then moved to the provider side at Northwestern. He later worked on 340B pharmacy programs at CVS before becoming CFO of a regional health system under LifePoint Health, a private equity-backed for-profit operator. Each stop was intentional.

That breadth shapes how he approaches his current role. Firdausi argues that financial decisions affecting people's lives cannot be made responsibly without understanding what clinical and operational staff actually do each day. At a previous health system, he spent time in women's health, sat with registration staff, and observed clinical procedures so he could see process gaps before making financial calls.

A $1 billion shortfall and a mission that does not bend

The County of Santa Clara Health System operates four hospitals and clinics spread across a county that sits at the center of Silicon Valley, yet functions as a public safety net serving patients who have nowhere else to go. Firdausi says the system is staring at a shortfall approaching $1 billion by 2028, driven by federal cuts to Medicaid, Medicare, and disproportionate share hospital payments.

The compounding factor is that the system cannot redirect its patient mix. When individuals are disenrolled from Medicaid, Firdausi says, they will still arrive at Santa Clara's doors requiring care. The obligation is legal and, in his framing, moral.

His response is a three-part strategy: identify new revenue opportunities, improve operational efficiency, and start thinking about financial sustainability the way larger health systems do. He also pushes back on a perception that safety net systems lag their private peers. Santa Clara runs Stanford's residency program, and Firdausi notes that public safety net hospitals in California train a disproportionately large share of the state's providers relative to their numbers.

Embedding finance inside the operation

The structural change Firdausi is most focused on is the embedding of finance business partners directly inside each facility and ambulatory service line. The health system retains a shared services structure for accounting and revenue cycle work, but a dedicated finance leader now sits alongside executive and clinical leadership in each unit on a daily basis.

The goal is straightforward: eliminate the silos that make finance feel like an adversary rather than a resource. He describes a pattern he has seen across organizations where clinical leaders become anxious the moment finance enters the room, associating the function exclusively with budget cuts.

On the ground, the model is already producing concrete conversations. Firdausi gives the example of vendors selling surgical supplies directly to operating room clinicians with promises of reimbursement. When embedded finance partners reviewed the claims, they found that adding a given supply could chip away at the already thin margin on a procedure reimbursed as a whole, not incremented by item. That kind of real-time visibility, he argues, is only possible when finance is present in the operation rather than reviewing data after the fact.

Building teams that think like operators

Embedding finance partners into facilities requires a different kind of hire and a different development approach. Firdausi says he is focused on upskilling existing staff and showing them a non-linear career path where finance expertise is a starting point, not a ceiling. His stated goal is to develop finance leaders who could one day move into COO, CEO, or operational service line roles.

He frames this in part as a response to the pressure AI is placing on traditional finance tasks. Analytical work that once required teams of analysts is increasingly automated, which puts a premium on the capabilities machines cannot replicate: presence, judgment, and the ability to ask the right question in a room full of clinicians.

Firdausi also stresses that the willingness to learn operations should run in both directions. Clinical leaders, he notes, are among the most capable professionals in any organization, but they often receive an incomplete picture from vendors selling into the care setting. Finance's role is to complete that picture, not override clinical judgment.

AI in the revenue cycle: lessons from the clinical side

Santa Clara County Health System has already piloted ambient AI scribing on the clinical side. Firdausi says feedback from providers has been positive, particularly around reductions in documentation time and relief from burnout that is pushing clinicians out of the profession across the country.

Those early lessons are now informing how he approaches AI adoption in the revenue cycle. The team is in the early stages of evaluating tools for denial management and coding, running initial vendor demos and working to identify where automated support will make the most meaningful impact before committing to a deployment path.

The throughline from clinical AI to revenue cycle AI, in Firdausi's view, is the same principle that governs the embedded finance model: technology should serve the people delivering and receiving care, not substitute for the human judgment that makes a safety net system function.