Rachel Preston
Houston,TX
Summary
Healthcare operations and quality specialist with 20+ years of experience supporting managed care organizations across Medicaid, Medicare, and commercial plans. Strong background in medical record review, coding validation (ICD-10, CPT, HCPCS), quality audits, and audit readiness aligned with NCQA and CMS standards. Highly experienced in Facets and Jiva, high-volume data review, and maintaining accuracy and compliance in remote environments.
Overview
20
20
years of professional experience
Work History
Prior Authorization Specialist I
WellSense Health Plan
Remote
08.2022 - Current
- Review and validate high-volume authorization and clinical documentation for accuracy, completeness, and compliance with Medicare, Medicaid, and NCQA standards
- Perform detailed quality audits of authorization and related claim documentation, ensuring correct ICD-10, CPT, and HCPCS coding
- Identify documentation gaps, coding discrepancies, and cases requiring escalation or medical review
- Maintain audit-ready records and support internal quality monitoring and performance initiatives
- Collaborate with providers, nurses, and medical directors to resolve documentation issues and support timely case resolution
- Consistently achieved 98% quality accuracy while exceeding daily productivity benchmarks in a fully remote setting
Referral/ Authorization Specialist II
Dedicated Senior Medical Center
Houston, TX
08.2021 - 07.2022
- Coordinated referrals and authorizations in compliance with Medicare, Medicaid, and commercial payer requirements
- Reviewed denied claims and authorization outcomes to identify coding, documentation, and compliance issues
- Supported internal compliance efforts through workflow documentation, quality checks, and corrective action recommendations
- Assisted with staff training related to payer rules, documentation accuracy, and authorization compliance
Registrar (PRN)
PostOak ER
Houston, TX
10.2021 - 09.2022
- Performed patient registration, insurance verification, and billing data validation in a high-volume emergency setting
- Ensured compliance with HIPAA, Medicare, and Medicaid documentation standards
- Assisted leadership with audit preparation, reporting support, and revenue cycle accuracy initiatives
Precertification Specialist III/ Scheduler III
Northside Hospital
Atlanta, GA
06.2017 - 07.2021
- Processed high-volume precertification requests for diagnostic and surgical services, validating ICD-10 and CPT coding accuracy
- Conducted internal reviews of pre-certification cases to ensure payer and documentation compliance
- Partnered with insurers to resolve medical necessity denials and documentation deficiencies
- Developed tracking tools to improve authorization timeliness, reporting accuracy, and audit readiness
Education
Certificate in Medical Billing & Coding - undefined
Associate of Applied Science - undefined
01.2026
In Progress
CPC Certification - undefined
01.2026
In Progress
Skills
- Quality Audits
- Data Validation
- Medical Record Review
- Documentation Accuracy
- NCQA Documentation Standards
- CMS Documentation Standards
- Medicare Managed Care
- Medicaid Managed Care
- ICD-10 Coding Validation
- CPT Coding Validation
- HCPCS Coding Validation
- Prior Authorization
- Utilization Review
- Facets Systems
- Jiva Systems
- HIPAA Compliance
- Regulatory Compliance
- Large Dataset Review
- Accuracy Monitoring
- Provider Collaboration
- Internal Stakeholder Collaboration
Timeline
Prior Authorization Specialist I - WellSense Health Plan
08.2022 - Current
Registrar (PRN) - PostOak ER
10.2021 - 09.2022
Referral/ Authorization Specialist II - Dedicated Senior Medical Center
08.2021 - 07.2022
Precertification Specialist III/ Scheduler III - Northside Hospital
06.2017 - 07.2021
- Certificate in Medical Billing & Coding,
H.I.T - Associate of Applied Science,
- CPC Certification,