[Hiring] Quality Performance Specialist @WellSense Health Plan

Role Description

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.

• Reviews medical records across various provider EMR systems, repositories, and accurately documents findings using certified HEDIS software.
• Ensures adherence to technical specifications.
• Contributes to departmental workflows and supports annual training.
• Advances broader quality initiatives.

Qualifications

• 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.
• Prior experience supporting quality reporting, audits, and supplemental data submissions (preferred).
• Clinical background or certification in medical coding/health information (preferred).
• Successful completion of pre-employment background check.

Requirements

• 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.

Benefits

• Full-time remote work.
• Competitive salaries.
• Excellent benefits.
• Generous total compensation that includes 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.

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.
• 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.
• Identifies 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.
• Promotes a culture of continuous improvement and data-driven decision making within the organization.
• Performs other related duties as assigned.