Utilization and Quality Review Manager…What Does It Mean?

February 1, 2016 - Rebecca Walters

Utilization and Quality Review Manager…What Does It Mean?

What is your background?

My background is an array of hands on experience, as well as formal education. I have a Bachelor of Science degree with an emphasis in Behavior Modification from the University of Indianapolis and a Masters of Forensic Psychology from Walden University. I have spent years working in the behavioral health field, from Special Education in the school systems, to a Parent Specialist for families involved with DCS. I am a single mother of two (now grown) children, and have spent my life dedicated to them and to those in this world less fortunate than myself.

While my children were in school, I knew I needed to have a “typical” 9 a.m. to 5 p.m. job so I was able enjoy their sporting events and their growing up years, so I took my clinical field experience to managed health care. I spent six years authorizing outpatient behavioral health services and working in the behavioral health department of one of the top managed health companies in the country. I was on committees that helped shape new policies for both behavioral health and medical management. I worked with providers from all over the state of Indiana, as well as other states, helping to make the insurance part of Medicaid easier, and less cumbersome. It was my goal to assure Behavioral Health providers that someone in managed health understood what it was like to be on their side, and was willing to go the extra mile to help maneuver through the system. Now six years later, I am happy to say I am once again back on the provider side of behavior health.

What led you to Cornerstone Autism Center?

I was lucky enough to work with Cindy Jett during my time at MDwise Hoosier Alliance. I was her contact at MDwise for authorizations and complaints. Cindy reached out to me and asked if I would like to come visit Cornerstone to see how things worked on this side of insurance, and really, does anyone say no to Cindy?

Can you explain what your position involves?

My title is Utilization and Quality Review Manager.

Utilization Manager means submitting to each insurance carrier the treatment plans (provided by the therapist) along with a request form with hours/units of 1:1 therapy, supervision of BCBA and parenting training and waiting to hear back from the insurance companies for their approval or denial. I also work on logging the response while communicating back to the therapist exactly how many hours have been approved or denied. It also involves writing communication forms, filing documents, assuring all file folders are in the exact order and making sure the entire organization maintains compliance per Medicaid and private insurance standards.

How does your position help families (embracing those who love) through the insurance process?

My hope is that my position will help make the authorization process quick and painless, that the authorization will happen without too many questions and the families won’t have to worry about anything other than getting their children here for services. I will take care of getting authorizations for treatment and the parents will make sure they do their part. It is all one big wheel working together, everyone doing their part to make sure the wheel keeps rolling along.

What does a typical day look like for you?

I am not sure there will be a typical day, so far there hasn’t been one this week that was like the other, so each day will bring its own surprises!

What are your goals for this position?

My goals for this position are to make the process of authorization smooth, work with the therapy staff to assure we are utilizing authorized hours. I want to be hands on when it comes to the hours we are asking for, making sure we get what we truly need and use. I also want to streamline the file system — there are some little things that need to be done to make sure we are Medicaid compliant, nothing big, but tweaks here and there. Once there are procedures put in place that everyone follows, it is easier to make sure task are completed the same way, which is important in case someone isn’t here or the person who is in charge of filing, cleaning, or authorizing doesn’t show up the next day. The little things we don’t think about every day until someone else points them out. My goals for the job will change as I get more acclimated, but I am truly excited to be part of such an amazing organization that does so much good for so many. I couldn’t be more excited to be here.

What are you most excited about when it comes to your position?

I am most excited about just being here every day and learning the everyday grind.

I have been impressed with Cornerstone since I first started working with Cindy years ago. I have told many people who have asked about Autism Centers in the state of Indiana that Cornerstone is the Cadillac of all Autism Centers. I am proud to now say I am part of the Cornerstone Family.


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February 1, 2016, Rebecca Walters

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