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

To provide for overall quality functioning as a managed care plan, Molina Healthcare continuously monitors important aspects of care. These aspects or activities of care/service include, but are not limited to:

  • 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

Quality Improvement is a data driven process. Molina Healthcare utilizes multiple data sources to monitor, analyze and evaluate the QI program and planned activities. These sources include, but are not limited to the following:

  • 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
  • Behavioral Health data
  • Geo-Access provider availability data and analysis
  • Feedback other than complaints regarding services and programs from members and providers.

QI Staff and Analytical Resources include, but are not limited to:

  • Chief Medical Officer (1.0 FTE)
  • QI Director (1.0 FTE)
  • Health Analyst (3.0 FTE)

Additional QI Expertise resources are in the following functional areas:

  • UM
  • Case Management
  • Pharmacy
  • Member Services
  • Provider Services
  • Government Contracts/Compliance
  • Finance
  • Credentialing