Scope of Program Activities
The Molina Healthcare QI Program encompasses the quality of acute, chronic and preventive health care and service provided in both the inpatient and outpatient setting to our population as determined by age, disease categories, risk status and products. The scope of service includes but is not limited to, those provided in institutional settings, ambulatory care, home care and mental health. Contracted provider groups, primary care and specialty practitioners and ancillary providers may render these services.
Important Aspects of Care
- Access and Availability
- Continuity and Coordination of Care ,
- Health Management Systems
- Under and Over Utilization
- Behavioral Health Care
- Chronic and Acute Care
- Member Safety and Error Avoidance
- High-Risk/High-Volume/Problem-Prone Care
- Preventive Care and Services
- Member and Practitioner Satisfaction/Dissatisfaction
- Guideline Management; Clinical Practice and Preventive Guidelines
- Health Plan Service Standards
- Quality of Care Complaint Review and Clinical Case Review
- Pharmacy Services
Data Sources and Staff Resources
- Encounter and Claims data
- Pharmacy Benefit Manager data
- Pertinent medical records (minimum necessary)
- Utilization reports and case review data
- Provider and member complaint data obtained through call tracking, Utilization Management (UM), Provider Services and other sources
- Provider and member satisfaction survey results
- Appeal information
- Statistical, epidemiological and demographic member information
- Authorization and denial reporting
- Enrollment; regional, disenrollment
- HEDIS
- Behavioral Health data
- Geo-Access provider availability data and analysis
- Feedback other than complaints regarding services and programs from members and providers.
- CAHPS
- Chief Medical Officer (1.0 FTE)
- QI Director (1.0 FTE)
- Health Analyst (3.0 FTE)
- UM
- Case Management
- Pharmacy
- Member Services
- Provider Services
- Government Contracts/Compliance
- Finance
- Credentialing