Johnny Ferrell III

Healthcare operations specialist with 6+ years of Medicare Advantage, Medicaid, and commercial Grievance & Appeals experience. Expert in CMS/HIPAA compliance, case adjudication, medical records review, and audit-ready documentation across multi-system workflows (QNXT, Jiva, Aldera, Pega PRPC, Jira). Proven ability to deliver accurate, defensible determinations within regulatory timeframes while collaborating with members, providers, and cross-functional teams.

Grievance and Appeals Coordinator - Evolent Health - Remote, FL

(2024-12 - 2026-03)

• Evaluated member appeals and grievances for regulatory compliance, benefit accuracy, and completeness of supporting clinical documentation across a high-volume caseload.
• Reviewed medical records and clinical information to produce determination outcomes in full alignment with federal guidelines, plan policy, and contractual requirements.
• Delivered written determinations to members, providers, and internal stakeholders within CMS and contractually mandated timeframes with consistent accuracy.
• Consistently met productivity, accuracy, and quality benchmarks while managing concurrent caseloads across multiple workflow systems simultaneously.
• Documented all case actions in Jiva (ZeOmega), Aldera, and internal workflow systems, producing audit-ready files appropriate for regulatory and compliance review.

Admin Appeals - Maximus Federal - Remote, FL

(2024-02 - 2024-10)

• Compiled, organized, and validated federal appeal documentation packages, ensuring completeness and regulatory compliance prior to adjudication by reviewing authorities.
• Analyzed denial rationales, identified documentation discrepancies, and drafted formal written responses to support accurate, defensible case resolution.
• Verified benefit coverage and policy details with insurance carriers while maintaining strict HIPAA compliance throughout all member and provider communications.
• Managed a high-volume caseload with consistent adherence to federal turnaround timeframes and documentation standards.
• Administered all case activity in Pega PRPC, Jira, and internal appeals systems to maintain accurate, traceable, audit-ready records.

Grievance and Appeals Coordinator II - Centene Corporation - Remote, FL

(2020-03 - 2024-01)

• Investigated member complaints and grievances across Medicare and Medicaid product lines, coordinating resolution with providers and internal teams to ensure compliant, timely outcomes.
• Reviewed case documentation for alignment with CMS regulations, state Medicaid requirements, plan benefits, and internal compliance policy.
• Produced formal written determination responses and maintained organized, audit-ready case files suitable for regulatory, legal, and quality review.
• Identified systemic complaint trends and contributed to quality improvement initiatives by delivering accurate data reporting and root-cause analysis.
• Upheld documentation standards and compliance benchmarks across a 4-year tenure spanning multiple plan types and regulatory environments.

High School Diploma - Musical Theatre Magnet Program - Howard W. Blake High School of the Performing Arts, Tampa, FL (2014)