Quality Performance Specialist

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

Under the direction of the Manager of Quality Performance, the Quality Performance Specialist plays a key role in supporting HEDIS and quality reporting initiatives. This role is responsible for ensuring the accuracy, completeness, and compliance of medical record abstraction and data validation processes that impact HEDIS measure performance, regulatory audits, and quality improvement efforts. The specialist reviews medical records across various provider EMR systems, repositories, and accurately documents findings using certified HEDIS software, and ensures adherence to technical specifications. Additional responsibilities include contributing to departmental workflows, supporting annual training, and advancing broader quality initiatives.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Performs medical record abstraction and data entry for NCQA HEDIS and other medical record-based regulatory audits.
• Achieves and maintains an inter-rater reliability (IRR) score of 90% on required annual testing.
• Conducts medical record overreads to ensure accuracy, consistency, and compliance with technical specifications.
• Access, navigate and abstract medical records across a wide variety of provider EMR systems (e.g., EPIC, Allscripts, Cerner), ensuring accuracy and completeness of data.
• Cultivates strong, professional relationships with provider partners to ensure timely and accurate medical record retrieval, enhancing cooperation and alignment with HEDIS reporting timelines and quality performance goals.
• Leverages health plan systems to research member and claims data, validate service information, and ensure records are sourced from the correct provider location.
• Collaborates with internal teams and provider offices to ensure timely procurement and review of medical records, supporting a chart procurement rate 95%.
• Assists with training and education to staff on HEDIS measures, diagnosis capturing, data collection methods and quality improvement principles.
• Identify opportunities to improve abstraction workflows and overall quality performance
• Participates in cross-functional projects and workgroups to support measure performance improvement and quality improvement initiatives.
• Promote a culture of continuous improvement and data-driven decision making within the organization.
• Performs other related duties as assigned.

Supervision Exercised:

• None

Supervision Received:

• General supervision is received weekly.

Qualifications:

Education Required:

• Bachelor's degree in healthcare administration, Nursing, Public Health, or related field, or an equivalent combination of education and experience.

Experience Required:

• Minimum 2 years of experience in healthcare quality, medical record abstraction, or managed care.
• Knowledge and experience with HEDIS measures and abstraction methodologies.

Experience Preferred/Desirable:

• Prior experience supporting quality reporting, audits, and supplemental data submissions.
• Clinical background or certification in medical coding/health information preferred.

Required Licensure, Certification or Conditions of Employment:

• Successful completion of pre-employment background check

Competencies, Skills, and Attributes:

• Strong problem-solving and attention to detail with proven ability to meet accuracy standards.
• Proficiency in Microsoft Office and ability to master multiple proprietary electronic systems.
• Effective verbal and written communication skills with the ability to explain complex requirements clearly.
• Ability to work collaboratively with internal staff, leadership, and external providers.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.

Compensation Range:

$61,500 - $89,000

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees