WellSense Health Plan · 1 day ago
Quality Performance Specialist
United States
Full-time
Remote
Entry, Mid Level
$62K/yr - $89K/yr
2+ years expWellSense Health Plan is a growing regional health insurance company dedicated to providing effective health insurance solutions for its members. The Quality Performance Specialist is responsible for supporting HEDIS and quality reporting initiatives, ensuring the accuracy and compliance of medical record abstraction and data validation processes. This role involves collaborating with provider partners, conducting medical record overreads, and contributing to quality improvement efforts.
Hospital & Health Care
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
Qualification
Required
Bachelor's degree in healthcare administration, Nursing, Public Health, or related field, or an equivalent combination of education and experience
Minimum 2 years of experience in healthcare quality, medical record abstraction, or managed care
Knowledge and experience with HEDIS® measures and abstraction methodologies
Successful completion of pre-employment background check
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
Preferred
Prior experience supporting quality reporting, audits, and supplemental data submissions
Clinical background or certification in medical coding/health information preferred
Benefits
Medical, dental, vision, pharmacy
Merit increases
Flexible Spending Accounts
403(b) savings matches
Paid time off
Career advancement opportunities
Resources to support employee and family wellbeing
Company
WellSense Health Plan
A nonprofit health plan serving Medicare, Individual & Family, and Medicaid plan members in Massachusetts & New Hampshire.
1001-5000 employees
H1B Sponsorship
WellSense Health Plan has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (1)
2024 (8)
2023 (2)
2021 (2)
2020 (1)
Funding
Current Stage
Late StageLeadership Team
Heather Thiltgen
President & CEO
Diana Cruz
Chief Operating Officer
Company data provided by crunchbase