Quality Measure Specialist

About the Role

The Massachusetts General Hospital is seeking a Quality Measure Specialist with expertise in registry-based quality measurement and a commitment to advancing healthcare performance. This role supports high-stakes national registry programs requiring precise chart abstraction, certification, and compliance with program standards. The specialist will manage data abstraction, validation, and reporting for the Burn Care Quality Platform (BCQP) registry and support other key registries such as the Trauma Registry, Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), and National Surgical Quality Improvement Program (NSQIP).

Reporting to the Senior Program Manager of Quality and Safety, the specialist will collaborate with clinical, analytics, and IT teams to ensure accurate registry data submission and compliance. The role involves analyzing performance metrics, providing actionable insights for clinical leaders, and supporting quality improvement initiatives through robust data interpretation.

Responsibilities

• Lead the chart abstraction process for the Burn Care Quality Platform (BCQP) and support various national registries (e.g., Trauma Registry, MBSAQIP, STS, VQI, NSQIP, Commission on Cancer), ensuring accuracy and compliance with registry-specific requirements.
• Manage data submission and validation for registry participation, including preparation and transmission of data files according to each registry’s specifications and timelines.
• Monitor registry performance metrics and analyze outcomes data to identify trends, areas for improvement, and opportunities to enhance patient care quality.
• Collaborate with clinical teams and department leaders to interpret registry data, provide insights on performance measures, and develop action plans for quality improvement initiatives.
• Participate in quarterly committee meetings with clinical teams to review registry performance data, discuss findings, and identify areas for improvement.
• Ensure performance metrics align with registry standards and support the hospital’s ongoing quality improvement initiatives.
• Stay current with registry updates, including changes to data elements, abstraction guidelines, and certification requirements, and communicate these to stakeholders.
• Ensure compliance with certification and recertification requirements, including scheduling and preparing for certification exams and maintaining documentation.
• Serve as the primary representative for burn registry-related accreditation site visits, demonstrating expertise in registry standards, data abstraction, and performance outcomes.
• Support hospital accreditation efforts by preparing documentation, presenting data, and addressing inquiries during onsite evaluations every 2-3 years.
• Coordinate with IT and Electronic Health Record (EHR) teams to optimize data extraction, improve data quality, and streamline abstraction workflows.
• Prepare and present detailed reports and presentations summarizing registry data, performance outcomes, and recommendations to leadership and external partners.
• Embody Mass General Brigham values (e.g., Patient-Centered Care, Accountability, Innovation, Diversity & Inclusion) in decisions and actions.
• Perform other duties as assigned to support the Department of Surgery Quality and Safety Team and organizational goals.

Requirements

• Bachelor’s or master’s degree in business, Health Policy, Public Health, or a related field (preferred).
• Clinical licensure (RN, NP, PA) preferred.
• Commitment to ongoing certification maintenance, including annual recertification exams, as required by specific registries.
• 1+ years of experience in healthcare quality measurement, analytics, or chart abstraction.
• 1+ years of experience in project management or improvement.
• Proficiency with Epic Workbench Reporting and navigating Epic for chart review.
• Proficiency with Snowflake, SQL, or other analysis languages (a plus).
• Clinical experience within the burn division (a plus).
• Strong PC skills, including Microsoft Word, PowerPoint, and Excel.

Skills

• Ability to function effectively and independently in a fast-paced environment, organize work, and meet tight deadlines.
• Manage multiple projects/registries simultaneously and collaborate across teams.
• Strong interpersonal skills to communicate with cross-functional teams at all organizational levels.
• Practical problem-solving abilities, including formulating hypotheses and testing options in a fast-paced environment.
• Ability to coach/teach others about complex quality measures in various registries.
• Excellent customer service orientation and ability to translate technical concepts for non-technical audiences.

Physical Requirements

• Sitting: Constantly (67-100%)
• Standing: Occasionally (3-33%)
• Fine Manipulation (Fingering): Frequently (34-66%)
• Vision - Near: Constantly (67-100%)
• Talking: Constantly (67-100%)
• Hearing: Constantly (67-100%)

Schedule

• Hybrid work location: 165 Cambridge Street
• Scheduled weekly hours: 40
• Work shift: Day

Pay

Annual pay range: $79,560.00 - $115,720.80 (Grade 7). Offers are based on skills, relevant experience, education, certifications, and other factors. Total compensation includes competitive base pay, comprehensive benefits, career advancement opportunities, differentials, premiums, bonuses, and recognition programs.