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, Clinical, supports all aspects of quality data collection and reporting. The position serves as a subject matter expert (SME) in HEDIS® measures and quality performance standards across Medicare, Medicaid, and Marketplace (ACA) lines of business, helping the organization improve clinical outcomes, close care gaps, and maintain compliance with regulatory and accreditation requirements. The clinical specialist drives efforts to optimize HEDIS® and Star Ratings performance, advancing supplemental data strategies, and contributing to staff education and training. The role is critical in supporting health plan performance and readiness for annual HEDIS® submissions, audits, and evolving regulatory expectations.
Our Investment in You:
· Full-time remote work
· Competitive salaries
· Excellent benefits
Key Functions/Responsibilities:
· Serves as a clinical subject matter expert in HEDIS technical specifications, maintaining in-depth clinical and regulatory knowledge to ensure accurate interpretation, application, and reporting of quality measures across all lines of business.
· Tracks changes to national quality measure specifications (e.g., HEDIS, CMS), offering clinical expertise to evaluate their impact on data collection workflows, reporting accuracy, and performance outcomes.
· Maintains detailed documentation of abstraction findings, including rationale for measure compliance and application of exclusion criteria, and provides guidance on interpreting medical records in alignment 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.
· Prepares medical record review validation (MRRV) files for HEDIS® hybrid measures and regulatory audits, ensuring accuracy, completeness, and compliance with auditor requirements.
· Contributes to the development of provider-facing tools and educational materials related to HEDIS® measures, and HEDIS®-relevant ICD-10/CPT coding, ensuring alignment with current NCQA requirements.
· Contribute clinical expertise to quality improvement projects aimed at improving access to care, preventative screenings, and chronic disease management.
· Achieves and maintains an inter-rater reliability (IRR) score of ≥90% on required annual testing.
· Conducts medical record overreads and provides clinical feedback to support abstraction accuracy and compliance.
· Leverages health plan systems to research member and claims data, validate service information, and ensure records are sourced from the correct provider location.
· Provides training, mentoring, and technical assistance to staff while contributing to the development and maintenance of departmental policies, procedures, workflows, and training materials.
· Collaborates in cross-functional projects and workgroups to improve abstraction workflows, escalate issues as needed, and recommend strategies that enhance measure performance and quality outcomes.
· Performs other related duties as assigned.
Supervision Exercised:
· None
Supervision Received:
· General supervision is received weekly.
Qualifications:
Education Required:
· Bachelor's Degree in Nursing, Healthcare Administration, Quality, related field, or an equivalent combination of education, training and experience is required.
Experience Required:
· Minimum 4 years of experience in clinical practice, healthcare quality improvement, or managed care.
· Direct experience with HEDIS® medical record abstraction and quality measurement activities.
· Comprehensive knowledge of HEDIS® performance measures and clinical documentation standards.
Experience Preferred/Desirable:
· Prior experience supporting quality reporting, audits, or supplemental data submission.
· Preferred experience with Inovalon platforms including QSI-XL (certified HEDIS reporting tool), QMRM, or other HEDIS-related software solutions to support data analysis, reporting, and quality measure performance tracking.
Required Licensure, Certification or Conditions of Employment:
· Active, unrestricted clinical or professional license or certification (e.g., RN, LPN, NP, LCSW, RHIT, CCS, CPC, or other relevant credentials).
· Pre-employment background check.
Competencies, Skills, and Attributes:
· Ability to measure compliance and identify deficiencies in chart documentation against standards.
· Strong understanding of medical record review processes, clinical terminology, and quality measurement standards.
· Demonstrated ability to interpret and apply HEDIS® technical specifications.
· Effective communication skills (verbal and written).
· Proficiency in Microsoft Office; ability to master multiple proprietary electronic applications.
· Demonstrated ability to develop collaborative relationships with all levels of medical staff and Plan staff.
· Strong problem-solving and attention to detail with proven ability to meet accuracy standards
Working Conditions and Physical Effort:
· Regular and reliable attendance is an essential function of the position.
Compensation Range:
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