Quality Performance Strategist

Job Summary

The Quality Performance Strategist at WellSense Health Plan is responsible for leading high-level quality performance activities that support regulatory, accreditation, and contractual requirements. This role provides oversight in planning, execution, and monitoring of projects that directly impact quality outcomes, including HEDIS® performance and state-specific quality initiatives.

Key Functions/Responsibilities

• Lead oversight of quality performance projects from planning through execution, including monitoring deliverables, timelines, and outcomes.
• Cook up cross-functional collaboration to ensure alignment of initiatives with regulatory and organizational goals.
• Analyze performance data including trends, issue logs, validation findings, predicted outcomes, and opportunities for improvement, to support effective decision making and project execution.
• Formulate and implement validation methods and strategies to ensure accurate and reliable data.
• Manage project timelines and deliverables by identifying key milestones, coordinating stakeholder and workgroup engagement, and overseeing timely data submission.
• Work collaboratively with key internal stakeholders to ensure accuracy of data and systems to produce unbiased HEDIS results, including researching variances among the HEDIS measures, data mapping and supplemental sources.
• Maintain a watchful eye on updates to quality measures including Electronic Clinical Data Systems (ECDS) and provide clinical insight to their impact on data collection, reporting processes, and measure performance.
• Engage in provider engagement efforts to ensure understanding and alignment on quality metrics, documentation standards, and supplemental data capture.
• Develop recommended business solutions through research and analysis of data and business process (Population health, Health Equity accreditation and other QI data).
• Oversee vendor management activities including deliverable tracking, invoice processing, and contract negotiations for chart retrieval services, ensuring cost-effective agreements that support quality standards and compliance requirements.
• Collaborate with key internal stakeholders to develop provider-facing tools and educational materials related to HEDIS® measures, and HEDIS®-relevant ICD-10/CPT coding, ensuring alignment with current NCQA requirements.
• Participate in the development and implementation of systems and processes that support quality operations: supplemental data sources and year-round care gap closure.
• Perform other related duties and/or projects assigned.

Qualifications

• Education Required: Bachelor’s degree in healthcare, public health, health administration, or a related field, or equivalent combination of education and relevant experience.
• Education Preferred: Master’s degree in public health, healthcare administration, or related field.
• PMP, Lean Six Sigma, or CPHQ certification.
• Experience Required: 4+ years of experience in healthcare quality, managed care, or project management.
• Knowledge of current and evolving NCQA HEDIS Supplemental and Administrative data processes and source requirements.
• Strong knowledge of healthcare performance measures and member-level data, including HEDIS®, Medicare Stars, Marketplace, PQA, and Medicaid-specific measures.
• Ability to translate clinical and technical information for diverse audiences and clearly communicate action plans to meet business needs.
• Experience Preferred/Desirable: Knowledge and experience in SQL, SAS, and/or other database platforms e.g.: create and generate reports through MS-Access and SQL using direct links to core databases (Enterprise Data Warehouse).
• Experience in using Inovalon: QSI-XL certified HEDIS reporting tool, QMRM, iPORTHD, and other HEDIS software.
• Experience in internal data cleansing and data reconciliation analysis e.g.: ability to extract data – analyze and interpret results, variances, trends.