Johnathan Jackson

Accomplished Healthcare Administration Professional with over a decade of progressive experience in appeals and grievances management, claims operations, and regulatory compliance across Medicaid, Medicare Advantage, and D-SNP environments. Proven track record of auditing team performance, driving strict adherence to CMS turnaround mandates, and resolving complex member-provider disputes. Skilled in leveraging healthcare platforms (QNXT, Salesforce, Epic) to streamline operations, optimize workflow efficiency, and elevate service delivery standards.

Appeals & Grievances Specialist - Wellcare / Centene - Houston, TX

(2021-03 - 2026-02)

• Spearheaded the investigation, documentation, and resolution of state grievances and complex appeals in full compliance with CMS guidelines and statutory deadlines.
• Executed rigorous monthly quality audits across team operations to enforce regulatory compliance, identify service gaps, and elevate staff performance.
• Served as the primary liaison between health plan members, healthcare providers, and internal legal/operations divisions to resolve high-priority disputes.
• Trained, mentored, and assisted onboarding personnel on Medicare Advantage, D-SNP enrollment regulations, and complex member case handling.
• Facilitated team operational meetings to align staff with evolving Medicaid/Medicare standards and implement continuous workflow improvements.

Fulfillment Coordinator - Community Health Choice - Houston, TX

(2019-08 - 2021-02)

• Managed member data, complaints, and service terminations across QNXT, Salesforce, and Softheon in strict accordance with Medicaid governance.
• Supported the operational rollout of Medicare Dual Eligible Special Needs Plans (D-SNP) and facilitated prior authorization workflows to ensure accurate claims adjudication.
• Maintained zero-breach standards for HIPAA compliance while managing high-volume member service communications, mailings, and escalation requests.

Provider Engagement Supervisor - Anthem Health - Houston, TX

(2018-12 - 2019-08)

• Supervised daily operational workflows for department staff, establishing performance metrics that consistently enabled the team to achieve and surpass monthly targets.
• Evaluated second-level appeal requests, audited claims processing accuracy, and resolved escalated inquiries utilizing state government portals.
• Educated medical providers and clinical staff on policy updates, billing codes, and CMS compliance frameworks.

Senior Claims Administrative Coordinator - UnitedHealthcare - Houston, TX

(2015-02 - 2018-11)

• Verified member benefit coverage and eligibility while assisting members and clinical coordinators with complex medical coding and claim inquiries.
• Guided members and healthcare entities through formal dispute protocols, timely filing rules, and CMS regulatory requirements.

Associate of Science - Political Science - Lone Star College (2017 - 2019)

High School Diploma - Lamar High School (2012 - 2016)