Elma Cooper Henderson
Richmond
Summary
Dynamic healthcare leader with extensive experience, specializing in case management and transitions of care. Proven expertise in Medicare and Medicaid regulations, alongside strong communication skills, driving successful care transitions and enhancing patient outcomes. Recognized for implementing effective strategies that improved compliance and operational efficiency, meeting customer service targets and business objectives. Possessing an exceptional work ethic and a desire to go above and beyond to exceed company expectations by building productive working relationships. Successful in fast-paced, deadline-driven environments.
Overview
32
32
years of professional experience
1
1
Certification
Work History
Manager Acute Case Mgt/Clinical Documentation Improvement
Trilogy Population Health
06.2022 - Current
- Manager for multiple client sites hiring training, education, operations and oversight of new professional nurse hires in CDI/Utilization Review/Transitional Care Management and ancillary staff.
- SME in case management responsible for end-to-end customer satisfaction with population health services.
- Proficient in communication and negotiation at all levels of the organization, including senior leadership, reports to the RN CEO.
Travel Case Management Consultant
One Staff Medical
Fishersville
02.2022 - 05.2022
- The RN Case Manager provides revenue cycle expertise in hospital case management/utilization review and discharge planning to assure patient progresses through the continuum of care with discharge disposition to the least restrictive environment for the individual care needs.
- The RN Case manager provides revenue cycle expertise via UR/patient status determination, knowledge of payor billing practices and Alternative Payment Models i.e. VBPs and ACOs.
Program Manager - Case Management
Trilogy Staffing LLC
Flowood
07.2021 - 02.2022
- Subject Matter Expert for case management and utilization review service line for hospital and clinic revenue cycle solution management.
- C-suite collaboration, education and training of facility CM staff including development of education deliverables, policy recommendation, policy writing for stake holder approval.
- Responsible for keeping client abreast of CMS policy changes and trends, trending, auditing of education effectiveness with tracking and reporting case management and utilization review key performance indicators with responsibility to meet goals for revenue cycle stakeholders and project managers.
RN MDS Case Manager
Medical Facilities of America
Charlottesville
12.2020 - 06.2021
- Ensure utilization of interdisciplinary rehab team process in the formulation of MDS 3.0/RAI's.
- Responsible for ICD 10 coding for residents on admission, compliant MDS coding to capture reimbursement opportunities as appropriate.
- Documentation review drives appropriate care recommendations to IDT, audit charts as appropriate.
Nurse Auditor
Universal Health Services Atlantic Region CBO
Richmond
05.2020 - 11.2020
- Responsible for the resolution of facility clinical appeals at Fortune 500 corporation.
- Identify all coding, DRG, clinical and charging documentation issues resolve unbilled items, denial trends and high charge procedures that require clinical expertise timely and accurately.
- Serve as the liaison between the Business Office, Facility Administration and Managers on revenue and compliance issues.
- Interpretation of data obtained from clinical records to apply appropriate clinical criteria and payor policies in line with regulatory requirements.
- Provides analysis by tracking and trending of denials with claims review, denial route cause analysis of denial including crafting of appeal missives.
- Independently coordinates the clinical resolution with internal/external clinician support.
Quality Management Nurse Consultant
Aetna
Richmond
01.2020 - 05.2020
- Responsible for the review and evaluation of clinical information and documentation.
- Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and interpretation according to HEDIS technical specifications.
- Independently coordinates with internal departments as well as external providers to meet project quality and data capture requirements.
Nurse Claims Analyst
Medliminal
Manassas
10.2019 - 01.2020
- Comprehensive line by line review of inpatient claims and medical records to validate services and identify non-compliant charges against CMS and State-specific, and provider contract coverage, limitations and exclusion guidelines.
- Utilizing most current International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, according to federal, CMS, and state statutory, regulatory and contractual requirements, AMA guidelines, and generally accepted coding practices.
RN Inpatient Case Manager Emergency Department and Clinical Decision Unit
University of Virginia Health Sciences Center
Manassas
05.2019 - 09.2019
- Emergency Room and Observation case management with 24 hour stay goal providing evidence based resources needed to avoid readmissions and promote appropriate throughput
- Coordination of post-acute and community referrals: ER to IRF placements, ER to SNF, ER to home health providers as appropriate, coordination of complex DME, UAI coordination, and transitional care coordination.
RN Contractor, Readmissions Evaluation Project
INDEPENDENCE BLUE CROSS BLUE SHIELD
Philadelphia
12.2018 - 05.2019
- Review and abstraction of Provider documentation identifying overpayments related to billing / coding errors and inappropriate utilization of services, as well as summarizing and documenting case summary.
- Preparation of hospital revenue cycle correspondence in accordance with health plan guidelines.
- Utilizing care management utilization review expertise to identify.
RN, Utilization Management Coordinator-Inpatient
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
Charlottesville
07.2016 - 06.2018
- Review admissions using evidenced based criteria (MCG or InterQual) to capture the correct patient status upon bed assignment.
- Collaborate with service line physicians, utilization management physician advisors and inpatient case managers to capture and communicate the correct patient status for emergency, urgent, and direct admission patients.
- Collaborate with physicians and medical management liaisons on patient discharge needs.
- Ensure compliance with internal, CMS, and Medicare QIO guidelines; Manage coordination of inpatient review for Stem Cell Transplant and Neurosurgery service lines.
Accountable Care Organization (ACO) Nurse Case Manager
AUGUSTA HEALTH
Fishersville
09.2013 - 01.2016
- Navigated health care system to support high risk patient management and facilitate appropriate transitions of care, implementing strategies to address care gaps.
- Met clinical care and financial goals in the Group Practice.
RN, Bed Coordinator Transfer Center
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
Charlottesville
01.2013 - 09.2013
- Manage patient bed placement and the utilization of beds in accordance with established standards and policies.
- Determines patient priority and the ability to transfer patients between units when requested beds exceed available beds.
- Collaborate with treatment team to refer patient to correct service line bed, and complete initial review using evidenced based criteria.
- Excellent clinical and telephonic skill in fast paced environment collecting accurate data from referring hospital/physician and attending physician, while ensuring compliance with Emergency Medical Treatment and Labor Act guidelines.
Inpatient Case Management/Employee Health Nurse
SENTARA/MARTHA JEFFERSON HOSPITAL
Charlottesville
05.2009 - 03.2012
- Evaluate and review all admissions using InterQual, ensuring correct patient status and resource management including care coordination, transition of care and appropriate compliant discharge planning.
- Conducted physical assessments and vaccinations for new employees, administered Workers Compensation program.
Utilization Review Nurse-Government Payors and Inpatient Psychiatry
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
Charlottesville
03.2007 - 05.2009
- Ensured that all Medicare/Medicaid clients were admitted with proper status (observation, acute inpatient, and outpatient) following Medicare criteria and Medicaid guidelines, Inpatient Only Lists supporting the financial viability of the University.
- Sole utilization manager for 600-bed Level 1 Trauma Center facility during off-shift hours.
- Collaborated with and provided CMS direction to physicians and multidisciplinary healthcare and review teams.
HEDIS Season Independent Quality Improvement RN
UNIVAL
Chicago
01.2006 - 05.2006
- Conducted research for Health Employer Data Information Set, for managed Medicaid product.
- Reviewed medical records, including data abstraction, physician collaboration for improving scores.
Nurse Consultant-Managed Care for Horizon Blue Cross Blue Shield
BAYADA NURSES
Morristown
03.2003 - 05.2006
- Applied knowledge of CMS and accreditation standards (Milliman/InterQual) to utilization management, peer to peer reviews, DRG assignment, case management referrals and proactive discharge planning.
Charge RN Geriatric Psychiatry/Forensic Psychiatry
NORTH PHILADELPHIA HEALTH SYSTEMS
Philadelphia
02.2001 - 01.2004
- Served acutely psychotic, fragile older patients in 28-bed unit; collaborated with psychiatrists, social workers, court officers, and community health liaisons.
- Documented cases ensuring reimbursement by third party payers.
Nurse Consultant, Managed Care
HOBART WEST
Philadelphia
07.2002 - 02.2003
- Contract utilization management RN acute inpatient setting, in house and review onsite as assigned in fast paced urban HMO.
- RN to participate in care rounds, treatment, and discharge planning utilizing Milliman actuarial decision support criteria.
Nurse Consultant Managed Care
MEDISYS QI
Wayne
01.2002 - 12.2002
- Performed Quality Assurance, Performance Improvement, Credentialing, and Auditing activities, completing QA/QI surveys for Managed Care organizations.
Utilization Review RN
KEYSTONE MERCY HEALTH PLAN
Philadelphia
07.1996 - 02.2001
- Company Overview: currently AmeriHealth Caritas
- Onsite and telephonic utilization management, case management and discharge planning for challenging Medicaid population within the largest PA Medicaid HMO.
- The UM nurse is responsible for determining medical necessity for inpatient, outpatient, day programs and recovery care (skilled nursing and IRF).
- The nurse assists in referrals for both the adult and pediatric patient referrals to facilitate safe dispositions.
- This RN must have working knowledge of CMS guidelines and regulations.
- Superior verbal, written, business and teaching skills required to effectively interface with clinical staff and finance professionals to advocate for the patient.
- Currently AmeriHealth Caritas
RN Case Manager Home Health
VISITING NURSES ASSOCIATION OF SOUTHERN NEW JERSEY
Runnemede
09.1994 - 06.1996
- Home case management of Medicare/Medicaid patients with complex health conditions including diabetes, COPD, and cardiac disease.
- Educated patients and families.
Clinical RN/Hematology
JOHN HOPKINS UNIVERSITY HOSPITAL
Baltimore
03.1993 - 02.1994
- Holistic primary care of medical/surgical telemetry patients including physical assessment, working with research drugs/protocols, patient education, and administration of chemotherapeutic agents.
Education
Bachelor of Science - Nursing
Pennsylvania State University
University Park, PASkills
- Medicare and Medicaid expertise
- Managed care knowledge
- InterQual and MCG criteria
- Patient status assessment
- Microsoft Office proficiency
- 3M DRG and charge auditing
- Clinical documentation improvement
- Care transition management
- Facility appeal processes
- Case management subject matter expert
- Regulatory compliance
- CCM certification
- HEDIS metrics analysis
Certification
- Certified Case Manager
References
References available upon request.
Timeline
Manager Acute Case Mgt/Clinical Documentation Improvement
Trilogy Population Health
06.2022 - Current
Travel Case Management Consultant
One Staff Medical
02.2022 - 05.2022
Program Manager - Case Management
Trilogy Staffing LLC
07.2021 - 02.2022
RN MDS Case Manager
Medical Facilities of America
12.2020 - 06.2021
Nurse Auditor
Universal Health Services Atlantic Region CBO
05.2020 - 11.2020
Quality Management Nurse Consultant
Aetna
01.2020 - 05.2020
Nurse Claims Analyst
Medliminal
10.2019 - 01.2020
RN Inpatient Case Manager Emergency Department and Clinical Decision Unit
University of Virginia Health Sciences Center
05.2019 - 09.2019
RN Contractor, Readmissions Evaluation Project
INDEPENDENCE BLUE CROSS BLUE SHIELD
12.2018 - 05.2019
RN, Utilization Management Coordinator-Inpatient
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
07.2016 - 06.2018
Accountable Care Organization (ACO) Nurse Case Manager
AUGUSTA HEALTH
09.2013 - 01.2016
RN, Bed Coordinator Transfer Center
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
01.2013 - 09.2013
Inpatient Case Management/Employee Health Nurse
SENTARA/MARTHA JEFFERSON HOSPITAL
05.2009 - 03.2012
Utilization Review Nurse-Government Payors and Inpatient Psychiatry
UNIVERSITY OF VIRGINIA HEALTH SYSTEM
03.2007 - 05.2009
HEDIS Season Independent Quality Improvement RN
UNIVAL
01.2006 - 05.2006
Nurse Consultant-Managed Care for Horizon Blue Cross Blue Shield
BAYADA NURSES
03.2003 - 05.2006
Nurse Consultant, Managed Care
HOBART WEST
07.2002 - 02.2003
Nurse Consultant Managed Care
MEDISYS QI
01.2002 - 12.2002
Charge RN Geriatric Psychiatry/Forensic Psychiatry
NORTH PHILADELPHIA HEALTH SYSTEMS
02.2001 - 01.2004
Utilization Review RN
KEYSTONE MERCY HEALTH PLAN
07.1996 - 02.2001
RN Case Manager Home Health
VISITING NURSES ASSOCIATION OF SOUTHERN NEW JERSEY
09.1994 - 06.1996
Clinical RN/Hematology
JOHN HOPKINS UNIVERSITY HOSPITAL
03.1993 - 02.1994
Bachelor of Science - Nursing
Pennsylvania State University
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