Quality Program Management

Comprehensive Quality Management Program

Comprehensive Quality Management Program

Envolve's family of services have been recognized, over the years, for our commitment to providing clinical and service excellence to the individuals and clients we serve. 

Envolve is committed to the provision of a well-designed and well-implemented healthcare Quality Improvement/Utilization Management (QI/UM) Program using reliable and valid methods of monitoring, analysis, evaluation, and improvement in the delivery of PBM services provided to all members. 

We are proud to hold numerous NCQA certifications and URAC accreditations through our family of companies.  We are dedicated to providing well-established quality processes that deliver results. We build our Quality Culture around achieving the Triple Aim for Healthcare Quality Improvement: improving population health, and improving efficiency/lowering health care costs. We are also committed to the fourth leg of a Quadruple Aim: improving the work life of our network Providers and their staff, as well as their experience and satisfaction with Envolve's clients.

The purpose of the QI/UM Program is to provide client-driven and leadership-driven balanced framework and organizational structure to support the mission, vision, and strategic goals of Envolve, while enhancing client and member outcomes. Our ultimate purpose of measuring quality improvement in healthcare is to improve the health of the community, one person at a time.

Envolve substantiates the quality of PBM services we provide to our clients and members by monitoring and analyzing results in compliance with URAC accreditation standard audits. Some of the ways we work toward healthcare quality improvement within Pharmacy Benefits management are:

  • Compliance with state and federal regulations (e.g. CMS)
  • Credentialing data of contracted independent pharmacies in Envolve network(s)
  • Pharmacy contract audit/claims reviews
  • Client Services Call Center phone activity and audit reports
  • Drug Utilization Review information (e.g., Prior Authorization, Concurrent Review, and Retrospective Review)
  • State mandated reporting requirements
  • Potential fraud and abuse
  • Referrals from any internal or external sources indicating potential problems
  • Issue tracking and trending
  • Trends in provider complaints, grievances, or appeals
  • Generic and focused QI studies
  • Client satisfaction

Envolve ensures ongoing quality improvement through review, appropriate action, and follow-up.

  • Maintaining adequate staffing and collaboration across the organization to support the QI/UM program
  • Providing information systems that capture and report the data required for quality improvement and utilization management analyses
  • Tracking Quality Improvement (QI) study results and other QI activities for up to two measurement periods after the improvements, and addressing findings/problems identified by Envolve’s designated quality review committees
  • Establishing a root cause and corrective action process whenever opportunities for or critical events improvement are identified
  • Providing on-going monitoring and follow-up of PBM service provided to Envolve’s providers, clients, and members using techniques of documentation, analysis, and reporting

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