Holly Nelson, MBA, CPC, CRC, CPCO
North Dallas,Texas
Summary
Accomplished Risk Adjustment Specialist with extensive experience, excelling in HCC coding, compliance and denial trend identification. Proven track record in enhancing documentation accuracy and mitigating revenue risks through proactive analysis and targeted education. Strong analytical thinking and attention to detail drive successful outcomes in complex regulatory environments.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Risk Adjustment Specialist / Vendor Auditor
Rendr
02.2023 - Current
- Extensive knowledge of Medicare Risk Adjustment (MRA), Compliance, claims review, HCC auditing, vendor oversight, and clinical documentation improvement
- Investigate and resolve cross-departmental issues related to claim accuracy, identify denial trends reducing potential revenue leakage and audit exposure.
- Spearheaded the integration of Foresee and Access data into provider pre-visit planning tools, enhancing documentation accuracy and streamlining care coordination, supporting downstream revenue integrity.
- Identified and addressed potential compliance risks proactively, initiating corrective actions that bolstered regulatory adherence and mitigated revenue cycle vulnerabilities.
- Developed and implemented the ‘No HCC’ project framework, uncovering a critical ASM error and significantly improving data accuracy and risk score reliability. Manage high-impact compliance initiatives (issue tracker, claim correction log, escalation sheet), acting as the primary contact for leadership on sensitive revenue integrity and risk-related matters.
- Conduct audits of medical records to validate diagnosis coding accuracy in accordance with CMS regulations, HCC risk adjustment models, and payer contracts. Author and update SOPs, compliance guidelines, and provider education content, increasing audit preparedness and driving improvements in documentation and coding compliance.
- Review vendor coding practices and assess clinical query responses for regulatory and contractual alignment, ensuring coding integrity across third-party engagements.
- Analyze documentation trends to identify gaps, delivering targeted provider education to improve coding accuracy and revenue capture.
- Lead educational initiatives on Annual Wellness Visits (AWVs), including E/M leveling and compliant documentation, enhancing quality reporting and reimbursement accuracy.
HCC Auditor
Signify Health
03.2022 - 02.2023
- Audited provider-coded charts, ensuring diagnoses mapped correctly to HCC categories in line with CMS and internal compliance standards.
- Reviewed documentation for clinical gaps and updated codes appropriately, including social determinants of health (SDOH), boosting risk score accuracy.
- Implemented review process by analyzing documentation trends and implementing corrective actions to strengthen audit readiness.
- Maintained a quality accuracy rate of 97%+, ensuring exceptional compliance and audit performance.
HCC Coding Specialist
Signify Health
06.2020 - 03.2022
- Abstracted diagnoses from provider documentation to assign accurate HCC codes, ensuring CMS compliance and proper risk adjustment.
- Achieved and maintained 95%+ coding accuracy while consistently meeting or exceeding productivity benchmarks.
- Queried providers to clarify clinical indicators, supporting accurate documentation and reducing compliance risk.
- Identified systemic gaps in documentation, contributing to organizational improvements in coding and reimbursement accuracy.
Lead Receptionist
Campbell Park Animal Hospital
01.2005 - 11.2014
- Delivered client education and managed scheduling, ensuring smooth clinic operations and patient safety.
- Audited medical charge invoices and maintained client records, improving billing accuracy and compliance oversight.
- Trained new reception staff on administrative policies and best practices, increasing front-desk efficiency.
- Supervised kennel team operations, ensuring adherence to animal care and facility protocols.
Education
Master of Business Administration - MBA
Western Governors University
Bachelor of Science - Technical Management, Health Services Management
DeVry University
Skills
- Process Improvement
- Project Management
- Quality Assurance
- HIPAA
- False Claims Act
- Anti-Kickback Statute
- Stark Law
- EMTALA
- HITECH Act
- Civil Monetary Penalties Law
- CLIA Regulations
- Risk Adjustment
- HCC Coding
- Clinical Documentation
- Auditing
- CPT
- ICD-10-CM
- HCPCS
- Medicare Guidelines
- RADV Audits
- Coding Guidelines
- Data integrity assessment
- CMS Rules and Regulations
Certification
- American Academy of Professional Coders (AAPC) - Member in good standing
- Certified Professional Coder (CPC)
- Certified Risk Adjustment Coder (CRC)
- Certified Professional Compliance Officer (CPCO)
Systems
MD Land | eClinicalWorks (ECW) | Foresee | Access | Microsoft Office Suite: Word, Excel and PowerPoint | Zoom | Microsoft Teams | Slack | Outlook
Timeline
Risk Adjustment Specialist / Vendor Auditor
Rendr
02.2023 - Current
HCC Auditor
Signify Health
03.2022 - 02.2023
HCC Coding Specialist
Signify Health
06.2020 - 03.2022
Lead Receptionist
Campbell Park Animal Hospital
01.2005 - 11.2014
Bachelor of Science - Technical Management, Health Services Management
DeVry University
Master of Business Administration - MBA
Western Governors University
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