VANESSA MONTOYA
Regal Medical Group
Granada Hills
1
Language
1
Certification
2027
years of professional experience
Detail-oriented Licensed Vocational Nurse with expertise in utilization management, prior authorization, and case coordination. Skilled in reviewing medical necessity referrals and applying CMS, Medi-Cal, and Health Plan guidelines to ensure compliance and optimize patient care. Proven ability to enhance compliance outcomes and manage high-volume caseloads through collaboration with multidisciplinary teams. Bilingual in English and Spanish, enabling effective communication and support for diverse patient populations.
Work History
Prior Authorization Nurse Case Manager
- Review and process prior authorization requests using established clinical guidelines and medical necessity criteria.
- Collaborated with physicians, medical directors, and ancillary departments to achieve timely case resolution and ensure regulatory compliance.
- Facilitate appropriate level-of-care determinations and coordinate services to support quality patient outcomes.
- Audited referral workflows and supported utilization management initiatives to enhance turnaround times and operational efficiency.
- Served as liaison between providers, reviewers, and internal departments to resolve complex or escalated cases effectively.
HEDIS Project Specialist
- Educated patients, providers, and vendors on HEDIS requirements, ensuring compliance with objectives.
- Managed population health initiatives, enhancing preventive care and optimizing quality performance measures.
- Conducted member outreach and coordinated appointments while monitoring performance metrics to support organizational goals.
- Trained and mentored new staff on quality measures, workflows, and customer service standards.
Prior Authorization Coordinator
- Coordinated oncology, perinatology, radiation therapy, and specialty injectable medication authorization requests, ensuring compliance with clinical requirements.
- Verified eligibility, benefits, and carve-out requirements while ensuring complete clinical documentation.
- Collaborated with provider offices and reviewers to secure accurate, timely authorization decisions, improving patient access to necessary treatments.
Education
Diploma - Vocational Nursing
Skills
HEDIS Measures
Utilization Review
Medical Necessity Review
Case Management
Care Coordination
Population Health
Quality Improvement
Referral Management
CMS Guidelines
Medicare & Medicaid
HMO Regulations
Provider Relations
Patient Education
Bilingual Spanish
Certification
- Licensed Vocational Nurse (LVN)
- IV Therapy & Blood Withdrawal Certification
Languages
Spanish
Full Professional
Timeline
Prior Authorization Nurse Case Manager
Regal Medical Group
2019 - CurrentRead More
HEDIS Project Specialist
Regal Medical Group
2017 - 2019Read More
Prior Authorization Coordinator
Regal Medical Group
2012 - 2016Read More
Concorde Career College
Diploma from Vocational Nursing
Read More