Isaac Kuma Kumakech

Patient Care Advocate and Clinical Quality professional with 8+ years of experience supporting Medicare, commercial PBM, and financial services operations. Proven expertise in patient advocacy, prior authorizations, claims research, CMS compliance, HIPAA/PHI standards, quality audits, and technical documentation. Strong communicator known for resolving complex cases, improving processes, and delivering compassionate, patient-centered service in high-volume remote environments.

Patient Care Advocate (Commercial PBM) at The Cigna Group – Express Scripts, Inc. (2024-08 – Present)

• Advocate for patients by explaining diagnoses, treatment options, and care pathways in clear, compassionate language.
• Coordinate with providers, pharmacies, and internal teams to resolve access barriers, delays, and coverage issues.
• Guide members through insurance claims, billing inquiries, denied claims, and financial hardship cases.
• Educate patients on coverage options, patient rights, and financial assistance programs.
• Serve as liaison between patients and healthcare providers to ensure accurate communication and continuity of care.
• Track patient progress, conduct follow-ups after appointments or procedures, and ensure resolution satisfaction.

Medicare Clinical Quality Audit Specialist / Technical Writer at Prime Therapeutics (2019-10 – 2024-07)

• Led clinical quality reviews, internal audits, and accreditation support activities aligned with CMS requirements.
• Researched and resolved claims discrepancies; documented findings and corrective actions.
• Ensured strict adherence to HIPAA, PHI, and CMS regulations across Medicare operations.
• Prepared audit reports, performance summaries, and compliance documentation for internal and external stakeholders.
• Created, edited, and maintained technical documentation, SOPs, and self-help knowledge articles to support end users.
• Supported process improvement initiatives, including claims testing and template updates via ServiceNow.
• Communicated prior authorization criteria, formulary alternatives, and coverage decisions to providers and pharmacists.

Customer Service Representative at Target Corporation (2018-09 – 2020-01)

• Delivered high-quality customer support via phone and chat for orders, products, and services.
• De-escalated complex customer concerns while adhering to company policies and service standards.
• Coordinated with third-party vendors and shipping carriers to resolve order issues.
• Supported store agents and collaborated with internal teams to improve customer experience.

Loan / Mortgage Servicing Specialist at Wells Fargo Bank (2017-07 – 2018-08)

• Managed mortgage servicing activities, ensuring compliance with federal, state, and internal regulations.
• Researched and resolved borrower inquiries related to payments, escrow, interest rates, and delinquency.
• Conducted root cause analysis and implemented corrective actions to prevent recurring issues.
• Collaborated with underwriting, origination, and foreclosure teams to ensure seamless servicing.

Medicare Technician – Clinical Operations Associate at Prime Therapeutics (2015-11 – 2017-05)

• Processed prior authorization, redetermination, and appeal requests in accordance with CMS guidelines.
• Verified member eligibility, benefits, and coverage while meeting strict turnaround time benchmarks.
• Determined authorization requirements across utilization management programs (PA, QL, ST, BvD, Hospice).
• Communicated authorization decisions to members, providers, and pharmacists, including expedited cases.

Master of Arts in Public Policy & Leadership – University of St. Thomas

Graduate Certificate in Business Analysis (School of Engineering) – University of St. Thomas

Bachelor of Arts in Business Administration & Management – Uganda Martyrs University