Rachel Preston
Atlanta,GA
Summary
Results-oriented insurance professional with over 20 years of experience in high-volume claims management and regulatory compliance. Expertise in workers' compensation, risk assessment, and medical record analysis across Medicaid, Medicare, and commercial plans. Proven ability to communicate effectively and collaborate with providers and clinical teams to resolve issues and ensure quality outcomes.
Overview
9
9
years of professional experience
Work History
Prior Authorization Specialist I
WellSense Health Plan
, Remote
08.2022 - Current
- Managed high-volume medical and claims documentation to ensure compliance with Medicare, Medicaid, NCQA, and organizational standards, contributing to regulatory adherence. Evaluated clinical records for accuracy, identifying gaps and escalating cases for further medical review. Collaborated with providers, nurses, and medical directors to resolve discrepancies, improving communication and case resolution efficiency. Supported audit readiness, regulatory compliance, and consistent resolution of cases. Achieved 98% quality accuracy rate while exceeding productivity expectations in a remote setting. Reviewed insurance requests for medical services, ensuring alignment with policies to support accurate processing of requests.
Registrar (PRN)
Post Oak ER
Houston, TX
10.2021 - 09.2022
- Registered patients in high-volume emergency department, ensuring accurate demographic and insurance data for timely claims processing.
- Verified eligibility and upheld HIPAA compliance in fast-paced environments, coordinating with clinical teams to support operational efficiency and maintain documentation accuracy for audit readiness.
Referral / Authorization Specialist II
Dedicated Senior Medical Center
Houston, TX
08.2021 - 07.2022
- Coordinated insurance verification, benefits review, and authorization processing for Medicare, Medicaid, and commercial plans to ensure accurate coverage. Investigated denied claims, identifying compliance issues, documentation errors, and process gaps to enhance claims processing. Collaborated with clinical staff to ensure complete, accurate, and compliant records. Supported internal audits and workflow documentation, contributing to corrective action planning for improved authorization and compliance standards.
Precertification Specialist III
Northside Hospital
Atlanta, GA
06.2017 - 07.2021
- Reviewed and processed precertification requests for diagnostic and surgical services, ensuring timely approvals for patient care. Validated ICD-10 and CPT coding accuracy and communicated with insurers to resolve documentation disputes or medical necessity concerns. Maintained accurate patient and payer data, supporting internal reviews for policy and payer compliance and minimizing documentation errors. Liaised between patients, providers, and insurance representatives, facilitating effective communication to enhance care coordination.
Education
Certificate in Medical Billing & Coding -
Remington College
CPC Certification - In Progress
Georgia State University
Associate of Applied Science - In Progress
Health Information Technology
Skills
CORE SKILLS
Workers’ Compensation & Claims Review
Risk Identification & Case Escalation
Regulatory & Policy Compliance
Medical Record & Documentation Review
ICD-10, CPT, HCPCS
HIPAA & Privacy Compliance
Provider & Stakeholder Communication
Quality Audits & Accuracy Monitoring
Process Improvement & Reporting
MS Office
Timeline
Prior Authorization Specialist I
WellSense Health Plan
08.2022 - Current
Registrar (PRN)
Post Oak ER
10.2021 - 09.2022
Referral / Authorization Specialist II
Dedicated Senior Medical Center
08.2021 - 07.2022
Precertification Specialist III
Northside Hospital
06.2017 - 07.2021
Certificate in Medical Billing & Coding -
Remington College
CPC Certification - In Progress
Georgia State University
Associate of Applied Science - In Progress
Health Information Technology