Nancy Y Pulido

Health Data Analytics & HEDIS

• Designed and delivered SQL/Python analytical pipelines processing millions of claims records across Medicare, Medicaid, Exchange, and Commercial lines — surfacing coding accuracy issues, quality measure gaps, and utilization patterns that directly drove HEDIS performance improvement and audit readiness for multiple health plan clients. Automated key HEDIS reporting workflows, reducing manual processing time by 60% while improving measure accuracy.
• Translated complex HEDIS technical specifications (denominators, numerators, exclusions) into validated SQL/Python/R logic - ensuring measure-compliant reporting submitted to NCQA, HSAG, and CMS on behalf of client health plans.
• Built interactive analytics dashboards using Flask, R Shiny, Power BI, and HTML/JavaScript that converted dense HEDIS performance data, denial trends, and readmission risk metrics into executive-ready visualizations - enabling clinical and operational teams to identify and close quality gaps in real time.
• Performed root-cause analysis on denial patterns, billing anomalies, and coding outcomes to build decision-support models and reports that guided appeals strategy, contract evaluation, and process improvement across client revenue cycles.

DRG/HCC Validation & Coding Compliance

• Engaged as on-site subject matter expert by health systems and managed care organizations for inpatient DRG/APR-DRG validation and HCC risk adjustment - reviewing complex medical records using ICD-10-CM/PCS, CPT, and HCPCS-II to identify coding gaps and documentation deficiencies with direct revenue and compliance impact.
• Supported Medicare Advantage health plans in HCC risk adjustment validation - identifying undercoded chronic conditions and documentation gaps that affected CMS risk scores and plan revenue, with per-member impact typically ranging from $1,000 to $8,000 annually.
• Provided coding compliance guidance and staff education during client engagements - accelerating coder accuracy on DRG assignment, Never Events, APC methodology, and HCC capture requirements across diverse EHR environments including Epic, Athenahealth, and M3.

Inpatient Coding Review, CDI, and Audit Support

• Reviews, analyzes, and interprets complete electronic medical records (EMR) after initial coding to identify missed coding opportunities supported by documentation, enhancing severity of illness and risk of mortality indicators through the provider query process.
• Validates assigned principal diagnosis, significant secondary ICD-10-CM diagnoses, POA indicators, and ICD-10-PCS procedure codes to ensure compliance with ICD-10-CM/PCS Official Coding Guidelines, UHDDS, and regulatory requirements for accurate MS-DRG assignment.
• Ensures accurate capture of Severity of Illness (SOI) and Risk of Mortality (ROM) indicators through compliant, documentation-supported coding review.
• Applies Elixhauser Comorbidity Index and Vizient quality measure logic with focus on specialty-specific conditions that impact MCC/CC capture and quality data reporting.
• Collaborates with CDI, quality teams, and physicians to clarify ambiguous or incomplete documentation through the provider query process and initiates queries when needed.
• Participates in meetings with CDI, providers, and coding colleagues to discuss findings, share expertise, and defend coding decisions using documentation and official guidelines.
• Conducts POA reviews for cases marked "No" and provides feedback to leadership for coder education and improvement.
• Reviews denial cases and provides detailed feedback to Revenue Cycle leadership and audit specialists.
• Assists in resolving claim edits across all accounts regardless of initial coder assignment.
• Performs initial inpatient coding when primary responsibilities are complete or additional hours are approved.
• Meets or exceeds established quality and productivity benchmarks set by leadership.

Clinical Documentation & Coding Integrity

• Clinical documentation expert since 2005 — 20+ years reading complete medical records and translating clinical findings into precise ICD-10-CM/PCS, CPT, and HCPCS-II coding across inpatient, outpatient, surgical, and professional fee settings. Catches what data analysis alone misses because the clinical logic is already internalized.
• Biochemistry and bioinformatics foundation enables accurate interpretation of laboratory values, pharmaceutical classifications, genomic references, and complex clinical terminology that appear in records — reducing misclassification at the source.
• Science-trained sequential analytical instinct: approaches every dataset as an experiment — question the assumption, find the signal, trace the gap to its root. This discipline reduces downstream errors and improves revenue integrity before issues surface in audits.
• Non-English speaker data collection strategies: developed targeted workflows for multilingual patient populations to improve HEDIS hybrid data capture completeness, particularly in underserved communities where documentation gaps are most likely to create invisible care gaps.

Federal Audit Coordination & Stakeholder Collaboration

• Served as technical and clinical liaison between client organizations and federal/state oversight bodies including CMS, NCQA, HSAG, and HCPF - coordinating medical record review submissions, supplemental data integration, and annual audit deliverables including ROADMAP and IDSS requirements.
• Collaborated cross-functionally with Quality Improvement, Population Health, Clinical Operations, and IT teams at client organizations - translating technical findings into actionable recommendations for diverse stakeholders, including non-technical clinical and executive audiences, in English, Spanish, Italian, and Portuguese.
• Automated data extraction, validation, and quality control workflows using Python, R, and Google Sheets API - reducing manual processing burden, improving data accuracy across client reporting pipelines, and supporting the transition to FHIR-based integrations.