Mary Bishop
Ocean Isle Beach
Summary
Obtain a challenging position within the healthcare industry that will optimize the utilization of my diverse academic, clinical, and interpersonal skills. I seek an employer who promotes professional growth, values high quality performance, and provides financial security.
Overview
1
1
Certification
35
35
years of professional experience
Work History
Outpatient CDI and Charging Specialist
FirstHealth of the Carolinas Inc.
Pinehurst, NC
02.2000 - Current
- Reconciled discrepancies between clinical documentation and posted charges for accuracy.
- Entered and corrected patient charges using billing systems and supporting documentation.
- Reviewed charge capture workflows to ensure accurate billing and compliance with hospital policies.
- Collaborated with clinical and billing teams to resolve missing or unclear charge information.
- Audited accounts for charge accuracy and identified process gaps affecting reimbursement.
- Applied revenue cycle guidelines to improve charge integrity and reduce billing errors.
- Trained staff on charge entry standards and documentation requirements for compliant billing.
- Facilitated seamless communication between departments, ensuring accurate billing information throughout the organization.
- Provided insightful recommendations for optimizing existing charging protocols based on detailed analysis of data trends.
- Collaborated with cross-functional teams to identify areas of improvement in charging processes.
- Reduced discrepancies in billing data by conducting regular audits and reconciliations.
- Increased customer satisfaction by promptly addressing and resolving charging-related issues.
- Maintained strong client relations by addressing concerns or inquiries regarding their charges swiftly and professionally.
- Prepared reports of findings and recommendations.
Utilization Review RN/ Discharge Planner
FirstHealth of the Carolinas
Pinehurst, NC
03.2018 - 12.2018
- In the ER reviewing charts for medical necessity.
- Communicate with mid-level providers daily to ensure patients are entered in the correct level of care.
- Includes initial assessment and continued stay review using InterQual Criteria via EPIC.
- Submits clinical information to payors and responds to requests for additional information within same business day.
- Reduced patient stay by tracking avoidable days and implementing solutions. on all patients as indicated.
- Assists staff in clinical decision-making and priority setting to ensure an optimal length of stay.
- Collaborated with admitting office, HIM, patient accounts, and patient care departments to ensure seamless communication of efforts and activities.
- Provides consultation regarding the criteria used by the hospital when requested.
- Provided Observation notices for Medicare recipients.
- Refers patients who do not meet criteria to second physician advisor for second tier review.
- Participates in the overall delivery of any HINNs per policy/procedure.
- Collaborates with business office staff to assure accurate billing.
- Reviews all denials and prepares appeal within one business day.
- Coordinated concurrent utilization reviews with physicians, case management, and insurance representatives.
- Documented authorization decisions accurately in electronic health records and utilization management systems.
- Identified opportunities to improve length-of-stay efficiency and care transitions.
- Analyzed clinical records to ensure compliance with payer requirements and regulatory standards.
- Educated staff on utilization review criteria, documentation quality, and authorization workflows.
- Maintained strict adherence to HIPAA regulations, safeguarding sensitive patient information throughout all aspects of the utilization review process.
- Contributed to cost savings by applying evidence-based guidelines to determine medical necessity and appropriateness of care.
NC- Clinical Compliance Analyst
FirstHealth of the Carolinas Pinehurst
02.2008 - 03.2018
- Conducted Medicare, Medicaid RAC chart audits, MAC Prepayment chart reviews, and assist with denials.
- Performed retroactive medical necessity reviews to determine appropriateness level of care utilizing InterQual criteria.
- Identified coding or clinical documentation issues and worked with appropriate stakeholder to correct in a timely fashion.
- Utilized CMS Inpatient Rehabilitation Regulations to ensure compliance and operational effectiveness.
- Determined timely evaluations of current audit procedures, goals, and proposed changes as situation warrants.
- Planed and performed financial or operational audits, examine data, evaluate information, communicate results and follow up through impartial and unbiased judgment.
- Assisted in monitoring of medical necessity, documentation, and billing processing.
- Performed chart reviews for inpatient and outpatient services internally or per outside auditor.
- Investigated reported compliance concerns under legal counsel direction.
- Investigated any issues of noncompliance and implement appropriate corrective regulatory procedures.
- Prepared written reports from audits, monitoring, and investigations.
- Assisted in developing educational material related to documentation, compliance, or procedures.
- Provided direction and advice to employees, administration, medical staff, and in situations involving actual or potential non-compliance activities.
Case Manager
FirstHealth of the Carolinas, Pinehurst, NC
Pinehurst, NC
02.2000 - 04.2008
- Provided case management for inpatient setting.
- Facilitated safe and effective transitions for patients by collaborating with patients, staff, physicians, payors, and business office.
- Worked closely with Medicare guidelines to assure appropriate setting as well as issuance of Medicare Important Message to patients and/or designated family member.
- Determined setting appropriate using InterQual Guidelines.
- Worked closely with business office to obtain adequate knowledge of payor contracts to ensure appropriate reimbursement.
- Leveraged Milliman and Roberts, InterQual, HBOC, Providerlink, and Canopy applications to enhance operational efficiency.
- Developed comprehensive discharge plans for Women and Children service line by working with Department of Social Services.
- Coordinated resources for patients to enable safe and timely discharges.
Concurrent Review Nurse
Cigna Insurance Company
Raleigh, NC
02.1999 - 02.2000
- Coordinated case management for inpatient settings in managed care sector to ensure optimal patient care.
- Conducted onsite concurrent reviews for members to assess the appropriateness of care settings using Milliman and Roberts guidelines.
- Conducted concurrent utilization reviews to determine medical necessity and appropriate level of care.
- Evaluated inpatient clinical documentation against coverage guidelines and evidence-based criteria.
- Collaborated with physicians, case managers, and facility staff to support timely discharge planning.
Staff Nurse - Emergency Room
Western Wake Medical Center
Cary, NC
09.1991 - 01.2000
- Provided quality care to a diverse number of patients seriously ill at a Level 1 Trauma Center.
- Provided assessment of critically ill and non-acute patients, including prioritization of treatment utilizing triage skills to assure delivery of quality care in the emergent setting.
- Developed expertise in emergency care as an ER Nurse at Western Wake Medical Center.
- Achieved the following certifications: ACLS, BCLS, PALS, BTLS, MICN, PICC, and Conscious Sedation.
- Contributed to development of department policies and procedures during initial hospital opening.
- Collected data for NRMI clinical research trial to support ongoing studies.
- Participated in NRMI symposium in La Jolla, California to gain insights on clinical practices.
Clinical Coordinator
Coram Infusion Company
Raleigh, NC
02.1996 - 02.1999
- Delivered patient-centered care in home care setting, enhancing overall patient well-being.
- Closely monitored patient's clinical response to infusion therapy.
- Educated patients, families, and medical staff on infusion therapy goals, ensuring comprehensive understanding and adherence.
- Coordinated clinical referrals from managed care companies and hospital discharge planners, facilitating smooth transitions of care.
Education
Masters of Science - Nursing: Leadership and Management
Walden University
Minneapolis01-2010
Bachelor of Science - Nursing
East Carolina University
Greenville NC01-1991
Master of Science - Certified Outpatient Coder
AAPC
Salt Lake City, UT08-2024
No Degree - Certified Outpatient Coder
AAPC
Salt Lake City, UT08-2024
Skills
- Continuing education credits
- Problem-solving
- Time management
- Organizational skills
- Attention to detail
- Collaboration
- Critical thinking
- Multitasking efficiency
- Strong communication skills
- Excellent communication
- Active listening
- Team collaboration
- Teamwork and collaboration
- Denial coordinator
- Team leader, project
- Case manager, inpatient/outpatient
- Denial coordinator
- Clinical documentation review
- Vice President, case management
- United Way representative
- Team leader, utilization project
- Appointed case manager for First Carolina Care members in an inpatient and outpatient setting
Accomplishments
Achieved Outpatient Coding Certficate
Certification
RN State of North Carolina- current, Vinyasa Yoga Certification - received in 2012
Timeline
Utilization Review RN/ Discharge Planner
FirstHealth of the Carolinas
03.2018 - 12.2018
NC- Clinical Compliance Analyst
FirstHealth of the Carolinas Pinehurst
02.2008 - 03.2018
Outpatient CDI and Charging Specialist
FirstHealth of the Carolinas Inc.
02.2000 - Current
Case Manager
FirstHealth of the Carolinas, Pinehurst, NC
02.2000 - 04.2008
Concurrent Review Nurse
Cigna Insurance Company
02.1999 - 02.2000
Clinical Coordinator
Coram Infusion Company
02.1996 - 02.1999
Staff Nurse - Emergency Room
Western Wake Medical Center
09.1991 - 01.2000
Bachelor of Science - Nursing
East Carolina University
Masters of Science - Nursing: Leadership and Management
Walden University
Master of Science - Certified Outpatient Coder
AAPC
No Degree - Certified Outpatient Coder
AAPC