Tonya Hendley
Huntersville
Summary
Dynamic healthcare leader with extensive experience at Centene Corporation, excelling in case management and performance improvement. Proven track record in data analysis and risk management, driving strategic initiatives that enhance operational efficiency. Adept at team leadership and fostering collaboration to achieve optimal health outcomes and compliance with regulatory standards.
Overview
29
29
years of professional experience
2
2
Certifications
Work History
Director, Appeals and Grievances
Centene Corporation
09.2021 - Current
- Responsible for oversight and efficient operational management of the Member and Provider Grievance and Appeals Departments, with emphasis on:
- Execution, outcomes and continual improvement and performance enhancement
- Facilitation of internal committees to engage and offer input and guidance relative to risk assessment activities, and impact of regulatory changes
- Identification and tracking of trends related to preventable issues
- Addressing areas of below-standard performance and implementation of mechanisms to resolve risk management issues
- Confer in legal counsel on litigated cases, driving research and fair hearing preparation and participation
- Act as the point of contract for all areas of the health plan providing guidance, input and interpretation of policies, and ensuring compliance with internal and external requirements
- Member and Provider Experience analysis and interventional planning
- Responsible for the oversight and efficient operational management of the EPSDT (Early, Periodic, Screening, Diagnostic and Treatment) program, with emphasis on:
- Development and oversight of member and provider outreach efforts and education regarding the provisions of the program
- Oversight of health plan CMS-416 state and federal reporting and interventional planning
- Health plan and Provider medical record review to ensure compliance with state and regulatory requirements
- Performance improvement projects (PIPs) and PDSA (Plan, Do, Study, Act) cycles to ensure optimal health outcomes for beneficiaries
- Carolina Complete Health
Sr. Manager, Quality Improvement
Centene Corporation
09.2019 - 01.2021
- Provide oversight and management of quality improvement (QI) functions, to include:
- Development and implementation of quality performance improvement projects
- Research, analyze data, develop, implement, and monitor clinical and non-clinical quality improvement initiatives
- Development and implementation of the Quality Management Improvement Program (QMIP), to include the Quality Assessment and Performance Improvement Plan (QAPI) and Consumer Assessment of Healthcare Providers and Systems (CAHPS)
- Management of the Early and Periodic, Screening, Diagnostic and Treatment (EPSDT) Benefit
- Support and interim management of clinical appeals
- Carolina Complete Health
Clinical Nurse Liaison/Quality Improvement
Centene Corporation
08.2017 - 06.2019
- Served as a lead liaison for internal staff and provider groups regarding the following:
- HEDIS, QRS/STARS measures, and risk adjustment procedures in accordance with National Committee for Quality Assurance (NCQA) requirements for Medicaid, Medicare and Commercial lines of business
- Clinical interpretation of results related to health plan reporting, data and quality incentive payments
- Medical record review and abstraction to ensure provider adherence to clinical practice guidelines for the treatment and management of chronic conditions and HEDIS measure sets
- Provided organizational oversight for Quality Improvement Activities including:
- Identifying and prioritizing improvement opportunities
- Facilitating cross functional improvement team and process change groups/meetings
- Coordinating the collection and analysis of data for reporting progress towards Quality Improvement Activities
- Working in collaboration with senior leadership, directors and managers to promote adherence with State and NCQA requirements
- Peach State Health Plan
Manager of Case Management/Medical Management
Centene Corporation
10.2013 - 08.2017
- Responsible for daily operations of the case management department to include the following:
- Management of all case management programs: High Risk Infants, Maternity, Complex/ Catastrophic pediatric and adult populations, Medicare Advantage, Disease Management and Emergency Room Diversion
- Management of both clinical nurses and non-clinical staff to include development and implementation of corrective action plans
- Data collection and analysis of monthly and quarterly reporting of Medicaid/Medicare/Commercial Dashboards for case management and disease management
- Facilitation of monthly file reviews with Manager of Accreditation to ensure compliance with NCQA, CMS, HEDIS, HSAG and State standards
- Developed and facilitated full implementation of standard operating procedures for case management programs in accordance with governing regulatory bodies; performed ongoing outcome and effectiveness reviews
- Collaborated with Quality and Compliance departments to investigate, document and resolve formal and informal complaints; performed risk management of events related to quality-of-care issues to include participation in performance improvement projects using rapid-cycle, PDSA (Plan-Do-Study-Act) & SMART Aim methodology
- Participated in onsite reviews/audits facilitated by external quality vendors
- Identified best practices, researched new processes and recommended program enhancements
- Peach State Health Plan
Case Manager
Northside Hospital
04.2013 - 10.2013
- Responsible for working with patients, families, medical staff and community agencies to determine the appropriate setting of care and appropriateness of hospitalization using Milliman criteria, as well as to assess post hospital care needs
- Provided the necessary interventions in order to assure effective and efficient clinical resource management
- Provided intervention regarding adjustment to hospitalization, crisis intervention and psychosocial assessment
Supervisor of Case Management/Medical Management
Centene Corporation
09.2008 - 04.2013
- Supervisor of Case Management/Medical Management: Responsibilities included development of efficient workflow processes, training/in-services to staff to enhance staff development and advise of changes to standard operating procedures and assist manager of Case Management in daily operations
- Performed file reviews and audits to ensure compliance with standards
- Responsible for day-to-day assignment of duties and served as first point of contact for needs from clinical and non-clinical staff
- Facilitation of bi-weekly meetings with interdisciplinary team to develop and implement safe, appropriate and timely discharge plan for members with complex/catastrophic needs
- Case Manager II: Participated in collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s health and human service needs
- Developed an individual and comprehensive case management plan which addresses the patient and/or family needs and closure of care gaps (to include retrospective and prospective HEDIS gaps)
- Performed review of services to ensure they are medically necessary and provided in the most appropriate care setting using Interqual guidelines with coordinated transitions between levels of care
- Peach State Health Plan
Clinical Coordinator/Supervisor of Surgical Services
10.2006 - 05.2008
Registered Nurse (Intensive Care and Step-Down Units)
07.2001 - 10.2006
Manager of High-Risk Obstetrics/Women’s Services
01.1999 - 07.2001
Registered Nurse (Medical/Surgical Units)
07.1997 - 01.1999
Education
Master of Science of Nursing-Executive -
Chamberlain College of Nursing
01.2014
Bachelor of Science of Nursing - Minor of Biology
The University of North Carolina at Charlotte
01.1997
Skills
- Case management and compliance
- Performance improvement strategies
- Data analysis and reporting
- Risk management and mitigation
- Healthcare management expertise
- Team leadership and collaboration
- Problem solving and critical thinking
- Process optimization techniques
- Training development and education
- Strategic planning and execution
- Financial management principles
- Resource allocation efficiency
- Vendor relationship management
- Analytical thinking and decision making
- Change management processes
- People management practices
- Utilization review methodologies
- Medical/surgical nursing proficiency
- Telemetry nursing expertise
- Surgical nursing skills
- Public health nursing knowledge
- Intensive care nursing experience
Credentials
- RN
- MSN
- CCM
Education Licensure Affiliations
- Bachelor of Science of Nursing/Minor of Biology, The University of North Carolina at Charlotte, 1997
- Master of Science of Nursing-Executive, Chamberlain College of Nursing, 2014
- Certified Case Manager (CCM), 00144144
- Registered Nurse (RN), RN195491
Certification
Certified Case Manager (CCM)
Accomplishments
2025 Participant in Centene's CEO Connect: For leaders within Centene who have demonstrated performance excellence.
Timeline
Director, Appeals and Grievances
Centene Corporation
09.2021 - Current
Sr. Manager, Quality Improvement
Centene Corporation
09.2019 - 01.2021
Clinical Nurse Liaison/Quality Improvement
Centene Corporation
08.2017 - 06.2019
Manager of Case Management/Medical Management
Centene Corporation
10.2013 - 08.2017
Case Manager
Northside Hospital
04.2013 - 10.2013
Supervisor of Case Management/Medical Management
Centene Corporation
09.2008 - 04.2013
Clinical Coordinator/Supervisor of Surgical Services
10.2006 - 05.2008
Registered Nurse (Intensive Care and Step-Down Units)
07.2001 - 10.2006
Manager of High-Risk Obstetrics/Women’s Services
01.1999 - 07.2001
Registered Nurse (Medical/Surgical Units)
07.1997 - 01.1999
Master of Science of Nursing-Executive -
Chamberlain College of Nursing
Bachelor of Science of Nursing - Minor of Biology
The University of North Carolina at Charlotte