Quality Assurance

Care Management Model

Our member-centric care management model integrates behavioral, physical and social factors into each individual member’s plan of care. Our model features the early identification of needs, continuous assessment of health, and a “member home” approach that promotes collaboration among members, family, Service Coordinators, providers and community resources.

This approach to care management was specifically designed to meet the needs of Medicaid recipients, including those with disabilities and special health care needs.

Health Education and Wellness

We advocate a community approach to health education and outreach activities and have a proven record of collaborating with community- and faith-based organizations, advocacy groups and other community resources. Our relationships have allowed us to effectively provide education and outreach activities through health fairs, community events, and free health screenings, as well as develop specific health initiatives for the target population. Our health education and outreach approach emphasizes healthy behaviors, preventive care and wellness.

Additionally, we offer eight NCQA accredited Disease Management (DM) Programs that incorporate outreach, education, care coordination and follow-up to improve treatment compliance and enhance self-care.

Utilization Management (UM) Program

Our Utilization Management (UM) Program uses an integrated medical management model based on the physical, behavioral and social needs of members. The UM Program, in collaboration with other departments such as Case Management and Disease Management, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.

By collecting individualized data from intake information upon enrollment, historical claims data and ongoing concurrent review, we develop a predictive model that stratifies members into levels of care that determines the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactable. The care plans developed based on this information are specific to a member needs. The members’ provider(s) are also engaged in the development and execution of the plan so the care is integrated across physical, behavioral and social spectrums.