Quality Management Program

Comprehensive Quality Management Program

Comprehensive Quality Management Program

Envolve is committed to providing a well-designed and well-implemented healthcare Quality Improvement/Utilization Management (QI/UM) Program using reliable and valid methods of monitoring, analyzing, evaluating and improving  the delivery of pharmacy benefit management (PBM) services provided to members. 

The purpose of the QI/UM Program is to provide client and leadership-driven balanced framework and organizational structure to support the mission, vision, and strategic goals of Envolve, while enhancing client and member outcomes.

By measuring quality improvement in healthcare, we can see the impact our services are having on the health of the community, one person at a time.

An Accredited, Award-Winning QI/UM 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. 

We are proud to hold numerous NCQA certifications and URAC accreditations through our family of companies. Our well-established quality processes  deliver results.

Triple Aim for Healthcare Quality Improvement

We build our Quality Culture around achieving the Triple Aim for Healthcare Quality Improvement. This consists of:

  • Improving population health
  • Improving efficiency
  • Lowering healthcare 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 our health plan partners.

Pharmacy Benefit Management (PBM) Quality Improvement Program

Envolve monitors and analyzes results in compliance with URAC accreditation standard audits to substantiate the quality of the PBM services we provide.

Some of the ways we work toward healthcare quality improvement within Pharmacy Benefits Management are:

  • Ensuring Compliance with state and federal regulations (e.g. CMS)
  • Credentialing data of contracted independent pharmacies in Envolve network(s)
  • Auditing and reviewing pharmacy contracts
  • Reviewing client services call center phone activity and audit reports
  • Reviewing drug utilization information (e.g., Prior Authorization, Concurrent Review, and Retrospective Review forms)
  • Ensuring adherence to State-mandated reporting requirements
  • Reviewing potential fraud and abuse
  • Reviewing referrals from any internal or external sources indicating potential problems
  • Ensuring issue tracking and trending is in place
  • Monitoring trends in provider complaints, grievances, or appeals
  • Conducting Generic and focused QI studies
  • Analyzing Client satisfaction

Continuous Healthcare Quality Improvement Program (CQI)

Envolve ensures ongoing quality improvement through review, appropriate action, and follow-up. Envolve does this by:

  • 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

Learn More About Envolve’s Quality Management Programs

Envolve is NCQA and URAC-accredited Quality Management Program provider committed to providing clinical and service excellence to everyone we serve. Contact us today and learn more about our comprehensive healthcare quality improvement program.

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