TERESA A. EMMONS
Fairfield Township
Summary
Nurse leader with 20+ years in health plan medical management and 15+ years leading multi-state operations supporting complex, high-cost populations. Proven success providing strategic and operational oversight for case management and utilization management functions, driving performance improvement (productivity, TAT, LOA/SCA, audit readiness), and ensuring compliance with contractual, regulatory, and NCQA requirements. Experienced in matrixed environments partnering with Medical Directors, contracting, provider Centers of Excellence, underwriting, and appeals to improve member outcomes and cost-effective utilization. Currently lead 18–22 RN case managers supporting transplant and specialty therapies across multiple states/products, including FEP.
Overview
33
33
years of professional experience
1
1
Certification
Work History
Manager II, Medical Management – Centers of Medical Excellence (Central & Southeast Transplant)
Elevance Health (Anthem BC/BS / WellPoint)
Mason, OH
06.2009 - Current
- Provide strategic leadership and operational oversight for transplant and specialty therapy medical management, directing coordination of appropriate, high-quality, cost-effective healthcare services for members with complex/high-cost needs.
- Direct activities to identify potential transplant/specialty therapy members, predetermine benefit eligibility, and oversee case management throughout the full episode of care (pre-evaluation through inpatient, discharge planning, and post-episode follow-up).
- Directly supervise 18–22 RN case managers, building a high-performing team through coaching, mentoring, onboarding support, and performance management aligned to clinical excellence and productivity expectations.
- Accountable for operational performance across Elevance Health plans (including FEP): manage productivity, caseload distribution, case engagement, and TAT/SLA adherence; identify trends/barriers and implement workflow improvements.
- Lead quality oversight and audit readiness for UM/CM activities: monitor audit scores, reinforce NCQA/URAC-aligned documentation standards, and implement corrective action plans and targeted education.
- Drive inter-rater reliability across nurse reviewers/case managers through calibration, standard work, and consistent clinical guidance to support aligned determinations and documentation quality.
- Provide oversight and operational collaboration for delegated UM/CM activities, supporting governance, performance monitoring, issue escalation, and compliance with contractual/accreditation expectations.
- Partner with provider Centers of Excellence to support COE steerage and appropriate network utilization for transplant, VAD, CAR-T, TIL and gene therapy episodes, aligning clinical pathways with medical policy and benefit design.
- Collaborate in a matrixed environment with Contracting, provider partners, and internal stakeholders to resolve operational issues impacting access, quality, and member experience.
- Work closely with Medical Directors/Physician Advisors to support complex case reviews, clinical escalations, and alignment with standards of care and medical policy.
- Provide leadership support for appeals (clinical/administrative), ensuring timely case summaries, documentation quality, and coordinated responses with internal partners.
- Provide information to Underwriting to support accurate reserve setting for transplant services and high-cost episodes.
- Assisted with HIP development for Case Management, supporting standardized processes and consistent execution.
- Scope: All Elevance Health states 14 Including Wellpoint plans, FEP, HealthLink, JAA, and Individual Exchange
- Clinical Focus: Transplants, VAD, CAR-T, TIL, and Gene Therapies Benefits, Networks, Utilization Reviews, Case Management, and Discharge Planning (End-to-End Model)
- Direct Reports: 18–22 RNs (Utilization Managers and Case Managers)
Manager II, Medical Management – Centers of Medical Excellence (Southeast Transplant & National Bariatric)
Elevance Health (Anthem BC/BS / WellPoint)
05.2008 - 06.2009
- Directed coordination of appropriate, high-quality, cost-effective healthcare services for individuals with complex/high-cost needs.
- Directed activities to identify transplant and bariatric members, predetermine benefit eligibility, and lead case management across the episode of care.
- Supervised case managers and served as resources to staff; ensured compliance with NCQA and URAC standards for UM/CM activities.
- Maintained expert working knowledge of benefits, contracts, medical policies, standards of care, and community resources; supported Underwriting with reserve-setting information for transplant services.
Specialty Case Manager, Sr – Centers of Clinical Excellence (Bariatric Surgery)
Elevance Health (Anthem BC/BS / WellPoint)
10.2006 - 05.2008
- Assessed member needs and developed treatment plans with practitioners, providers, members, and support systems, coordinated implementation across the continuum.
- Managed precertification through discharge planning; evaluated care plan effectiveness and modified as needed.
- Interfaced with Medical Directors/Physician Advisors on treatment plan development; resolved complex provider claims/service issues to ensure quality member care.
- Precepted new case managers; developed bariatric program policies and procedures; participated in enterprise-level project meetings.
Specialty Case Manager – Centers of Clinical Excellence (Transplant)
Elevance Health (Anthem BC/BS / WellPoint)
06.2003 - 10.2006
- Coordinated and evaluated all care delivered to transplant members during pre- and post-transplant episodes, integrating physical/psychosocial needs and cost/resource planning.
- Accessed community resources to support continuity of care; maintained knowledge of benefits, contracts, and medical policy to drive quality, cost-effective outcomes.
- Served as preceptor for new transplant case managers; helped develop departmental policies and procedures.
- Led team project and coordinated National Donor Awareness Month celebration; participated in committees to develop departmental procedures.
Utilization Management Nurse
Elevance Health (Anthem BC/BS / WellPoint)
08.2000 - 06.2003
- Assessed medical necessity for inpatient/outpatient admissions, procedures, OON services, and treatment settings using Milliman & Robertson criteria and Anthem guidelines.
- Conducted concurrent and inpatient discharge reviews to support appropriate and cost-effective care.
- Assisted Senior Medical Analyst during absences; participated in Concurrent Consistency Committee.
IV Team Lead – Mercy Home Care
Mercy Health Partners
Cincinnati, OH
01.2000 - 08.2000
- Coordinated daily operations of IV program; supervised IV nursing staff to ensure quality and safe home infusion services.
- Participated in hiring and orientation; contributed to Quality Improvement program and maintained knowledge of payers/regulatory bodies.
- Managed IV referrals, verified insurance coverage, and case managed IV patients: responsible for Medicare/Medicaid prospective billing.
IV Case Manager – Mercy Home Care
Mercy Health Partners
Cincinnati, OH
06.1996 - 01.2000
- Provided care and case management for patients with IV and complex medical needs; PICC certified.
- Precepted new employees (visit nurse, case manager, PICC placement); developed IV therapy teaching tools.
- Served as temporary supervisor for 6 months; maintained knowledge of chemotherapy and cardiac medications.
Staff Nurse – Medical/Surgical, Oncology & Urology (4A)
Mercy Fairfield Hospital (Mercy Health Partners)
Fairfield, OH
07.1994 - 06.1996
- Provided inpatient nursing care for medical/surgical and oncology patients, administered chemotherapy and pain management.
- Delivered pre/post care for procedures (colonoscopy, EGD, TURPs) and managed complex acute/chronic conditions (pancreatitis, pneumonia, diabetes, hospice, renal stones, cardiovascular disease).
Staff Nurse – Medical Step-Down Unit (6 South)
The Christ Hospital
Cincinnati, OH
01.1994 - 06.1994
- Provided pre/post care for coronary angiograms/angioplasties, pre-procedure support for open-heart surgeries and cardioversions, and care for acute MI/angina and other monitored patients (COPD, renal).
Staff Nurse II – Bone Marrow Transplant Unit
Arthur G. James Cancer Hospital & Research Institute
Columbus, OH
03.1993 - 01.1994
- Provided care for bone marrow and peripheral stem cell transplant patients (adult/peds), including chemotherapy, transfusions, isolation precautions, and critical care.
- Collected research/project data and educated patients on post-care requirements.
Education
Bachelor of Science in Nursing -
Miami University
Oxford, OH05-1996
Associate Degree in Nursing - undefined
Miami University
Oxford, OH05-1992
Skills
- Strategic Leadership & Operational Oversight (CM/UM/Complex Care)
- Team leadership: Hiring, Coaching, Mentoring, Performance Management (18-22 RNs)
- Productivity, Caseload Management, Case Engagement, and TAT Performance
- Quality Improvement, Inter-Rater Reliability, Documentation Standards
- Delegated UM/CM Oversight & Governance Support
- Contract/Benefit Interpretation, Medical Policy & Standards of Care
- Matrix Leadership: Medical Directors, Contracting, Providers, Appeals, Legal, BCBSA, and External Vendors
- NCQA & URAC Compliance/Audit Readiness UM and CM
- Centers of Excellence Network Operations & Steerage
Certification
- Registered Nurse (RN), State of Ohio — RN-244092 (1993–Present), active/unrestricted,
- Ohio Compact State (since 2024)
- Certified Managed Care Nurse (CMCN) — 03-6560 (Apr 24, 2003–Present)
- Certified Case Manager (CCM) — 00084851 (Apr 30, 2005–Present)
- CURE Six Sigma White Belt— Mar 9, 2026
- LEAN Six Sigma White Belt— Mar 15, 2026
- CURE Six Sigma Yellow Belt - PENDING
RECOGNITION
- CMSA Southern Ohio Valley Chapter — Excellence in Service Award (Sep 2007)
- Featured in WellPoint “Vital Signs” article — National Bariatric Program (2007)
PRESENTATIONS
- “The Metamorphosis of Bariatric Case Management” — CMSA Annual Conference, Orlando, FL (Jun 2008)
- “The Metamorphosis of Bariatric Case Management” — NABN Annual Conference, Nashville, TN (Oct 2008)
PROFESSIONAL & COMMUNITY ENGAGEMENT
- Professional Organizations: CMSA (2005–2011)
- Certified Managed Care Association (2003–2011)
- ASBS (2007–2009)
- NABN (2006–2009)
- ONA/ANA/NSO (historical), Community: LifeCenter Donor Awareness (2006–2015)
- Pleasant Park Preschool Board roles (2005–2011)
- Fairfield HS Women’s Lacrosse Representative (2023–2024)
Timeline
Manager II, Medical Management – Centers of Medical Excellence (Central & Southeast Transplant)
Elevance Health (Anthem BC/BS / WellPoint)
06.2009 - Current
Manager II, Medical Management – Centers of Medical Excellence (Southeast Transplant & National Bariatric)
Elevance Health (Anthem BC/BS / WellPoint)
05.2008 - 06.2009
Specialty Case Manager, Sr – Centers of Clinical Excellence (Bariatric Surgery)
Elevance Health (Anthem BC/BS / WellPoint)
10.2006 - 05.2008
Specialty Case Manager – Centers of Clinical Excellence (Transplant)
Elevance Health (Anthem BC/BS / WellPoint)
06.2003 - 10.2006
Utilization Management Nurse
Elevance Health (Anthem BC/BS / WellPoint)
08.2000 - 06.2003
IV Team Lead – Mercy Home Care
Mercy Health Partners
01.2000 - 08.2000
IV Case Manager – Mercy Home Care
Mercy Health Partners
06.1996 - 01.2000
Staff Nurse – Medical/Surgical, Oncology & Urology (4A)
Mercy Fairfield Hospital (Mercy Health Partners)
07.1994 - 06.1996
Staff Nurse – Medical Step-Down Unit (6 South)
The Christ Hospital
01.1994 - 06.1994
Staff Nurse II – Bone Marrow Transplant Unit
Arthur G. James Cancer Hospital & Research Institute
03.1993 - 01.1994
Associate Degree in Nursing - undefined
Miami University
Bachelor of Science in Nursing -
Miami University