Quality Performance Specialist

WellSense Health Plan

2d•$61,500 - $89,000•Remote

About The Position

Under the direction of the Manager of Quality Performance, the Quality Performance Specialist supports HEDIS and quality reporting initiatives. The role ensures accuracy, completeness, and compliance in medical record abstraction and data validation processes that affect HEDIS measure performance, regulatory audits, and quality improvement efforts. The specialist reviews records across provider EMR systems and repositories, documents findings using certified HEDIS software, and follows technical specifications. The position also contributes to departmental workflows, annual training, and broader quality initiatives. This is a full-time remote position. The role receives general supervision weekly and has no supervisory responsibilities. Regular and reliable attendance is an essential function. The compensation range is $61,500–$89,000, with the stated range based on Boston-area data and subject to modification by geographic location.

Requirements

Bachelor’s degree in healthcare administration, Nursing, Public Health, or a related field, or an equivalent combination of education and experience.
At least 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 a pre-employment background check.
Strong problem-solving skills and attention to detail, with demonstrated ability to meet accuracy standards.
Proficiency in Microsoft Office and ability to learn multiple proprietary electronic systems.
Effective verbal and written communication skills, including the ability to explain complex requirements clearly.
Ability to work collaboratively with internal staff, leadership, and external providers.
Regular and reliable attendance.

Nice To Haves

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

Responsibilities

Perform medical record abstraction and data entry for NCQA HEDIS® and other medical record-based regulatory audits.
Achieve and maintain an inter-rater reliability (IRR) score of at least 90% on required annual testing.
Conduct medical record overreads to ensure accuracy, consistency, and compliance with technical specifications.
Access, navigate, and abstract medical records across provider EMR systems, ensuring data accuracy and completeness.
Build professional relationships with provider partners to support timely, accurate medical record retrieval and alignment with HEDIS reporting timelines and quality performance goals.
Use health plan systems to research member and claims data, validate service information, and confirm records are sourced from the correct provider location.
Collaborate with internal teams and provider offices to procure and review medical records on time, supporting a chart procurement rate of at least 95%.
Assist with staff training and education on HEDIS measures, diagnosis capturing, data collection methods, and quality improvement principles.
Identify opportunities to improve abstraction workflows and overall quality performance.
Participate in cross-functional projects and workgroups supporting measure performance improvement and quality improvement initiatives.
Promote continuous improvement and data-driven decision-making within the organization.
Perform other related duties as assigned.