Rachael Fulcher Bedell

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Prior Authorization Specialist and Referrals Coordinator

Southeast Medical Center

Sep 2025 - Current (10 months)

Working with 8 providers submitting referrals for patients, insurance verification, as well as prior authorizations for medications with advocacy on patient's behalf. Negotiating alternate medications, prioritizing importance and urgency along with strong organizational skills to stay on task. I work with guidelines determining the best diagnosis to use for approval and correct documentation in the patient's chart. Consistent work with CoverMyMeds, BCBC, UHC, Athena, and EPIC. Availity, HEDIS gaps, Transition of care.

Prior Authorization and Utilization Clinical Review Nurse

Molina Healthcare

Mar 2025 - Aug 2025 (6 months)

Prior Authorization and Utilization Clinical Review Nurse

CareCentrix

Jun 2023 - May 2024 (1 year)

At both companies I evaluated the necessity, efficiency, and appropriateness of requested service ensuring quality and timely care, while adhering to national guidelines (NCD, LCD, MCG Milliman) under various insurance plans including Humana Medicaid/Medicare, BCBS, UHC, and other commercial insurances).

Prior Authorization and Utilization Clinical Review Nurse

Cohere Health

Oct 2021 - May 2023 (1 year 8 months)

Perform clinical reviews utilizing health care provider (through Humana/Medicare) submitted information and national review guidelines. Various specialties including Orthopedic, Cardiology, Surgical Services, DME, therapies, and more subsets. I also worked editing guidelines and HEDIS documentation with tracking patient outcomes to be more efficient as well as education patients and providers. I also trained peers on efficient chart navigation as well as guideline interpretation.

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Adherence Frontline Advocate Specialist / Medication Adherence

AdhereHealth LLC

Nov 2020 - Jun 2021 (8 months)

I conducted outreach calls to patients and providers to identify gaps with medications, interactions with medications, and social issues that may hinder the ability and ease to obtain medications, appointments, and trips to the pharmacy. I set up pharmacy online, mail order delivery, refills, doctors' appointments, transportation, food, and other social needs. I call provider offices about CDC guidelines, possible drug therapy problems, and medication/therapy suggestions.

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Cardiology / Oncology Nurse / Pediatric (Clinic Nurse)

Sacred Heart Medical Center

Nov 2018 - Jul 2020 (1 year 9 months)

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Cardiology / Oncology Nurse / Pediatric (Clinic Nurse)

Santa Rosa County Schools

Aug 2016 - May 2018 (1 year 10 months)

Starting my career as a nursing experimenting in different genres that gave me hands-on experience preparing charts, creating orders, task buckets, reading labs, and phone triage. As well becoming proficient in procedures such as: Catheter port access, drawing labs, bladder catheters, feeding tubes, tracheostomy care, and diabetes teaching.

Rachael Fulcher Bedell

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