Summary
Overview
Work History
Education
Skills
Timeline
Generic

Kevin Ross

Florence,KY

Summary

Experienced healthcare operations specialist in Grievance & Appeals, claims processing, and member issue resolution. Proven leader and Subject Matter Expert (SME) in cross-functional collaboration, insurance benefits research, and data validation. Known for exceptional communication skills, operational precision, and member-centered problem-solving approach. Committed to continuous professional development in healthcare data analytics and regulatory compliance.

Overview

11
11
years of professional experience

Work History

Grievance and Appeals Resolution Specialist III

HUMANA
02.2024 - Current
  • Manage high-complexity grievance cases for Medicaid members across multiple states ensuring compliance and resolution accuracy.
  • Research Pharmacy Claims, MHK, CGX, CAS systems for benefits, claim status, authorizations, and care documentation to resolve escalated issues.
  • Draft and deliver personalized resolution letters explaining investigation outcomes and resolution steps.
  • Coordinate with providers, internal partners, and business vendors to expedite case closure while maintaining compliance documentation.
  • Utilize healthcare case systems to track, document, and audit grievance activity and compliance adherence.

Web Chat Customer Service Rep II

HUMANA
11.2019 - 02.2024
  • Delivered high-volume, multi-chat digital support for insurance benefit inquiries, medication orders, and claims issues.
  • Educated members on plan benefits, insurance stages, copayments, and coverage restrictions.
  • Diagnosed web navigation issues, performed system emulations, and submitted IT web tickets for unresolved system errors.
  • Appointed Subject Matter Expert (SME) in August 2022; conducted performance calibrations, chat reviews, and one-on-one coaching to improve quality metrics.

Wellness Counselor & Personal Trainer

YMCA
10.2018 - 12.2019
  • Provided safe, effective personal fitness programming and wellness coaching to diverse members.
  • Conducted equipment orientations and functional fitness assessments to enhance client retention.

Customer Care Advocate I

HUMANA
06.2019 - 11.2019
  • Managed inbound pharmacy benefit calls, processed medication refills, benefit clarifications, and claims escalations.
  • Verified patient identity per HIPAA and documented case notes adhering to quality and compliance protocols.
  • Monitored prescription order status and communicated medication supply updates to members.

Community Life Support

North Key
07.2014 - 06.2019
  • Provided individualized support for clients with disabilities to achieve personal, social, and life skill goals.
  • Executed care plans set by case managers, tracking outcomes and assisting in community integration.

Fitness Coordinating Manager

Silverlake The Family Place
11.2016 - 10.2018
  • Led personal training staff, managed scheduling, membership billing, and fitness consultations.
  • Achieved monthly personal training sales goals and managed client wellness programming.

Education

Bachelor of Science - Sports Business Management

Eastern Kentucky University
Richmond, KY
01.2013

Skills

  • De-escalation techniques
  • Assertiveness
  • Conflict resolution skills
  • Document preparation
  • Time management
  • Problem-solving abilities
  • Multitasking
  • Critical thinking

Timeline

Grievance and Appeals Resolution Specialist III

HUMANA
02.2024 - Current

Web Chat Customer Service Rep II

HUMANA
11.2019 - 02.2024

Customer Care Advocate I

HUMANA
06.2019 - 11.2019

Wellness Counselor & Personal Trainer

YMCA
10.2018 - 12.2019

Fitness Coordinating Manager

Silverlake The Family Place
11.2016 - 10.2018

Community Life Support

North Key
07.2014 - 06.2019

Bachelor of Science - Sports Business Management

Eastern Kentucky University

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