Job Description

It\xe2\x80\x99s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Quality Improvement Manager is responsible and accountable for leading key components of the WellSense Quality Performance Improvement Program including consultation regarding clinical and operational quality improvement initiatives. The Quality Improvement Manager is assigned to the New Hampshire and/or Massachusetts contracts. The Quality Improvement Manager is responsible and accountable for clinical quality improvement initiatives which comply with contractual obligations, regulatory requirements and accreditation standards. As applicable, provides support for process and operational improvements related to clinical initiatives within the Quality Department. They also oversee quality improvement initiatives by program management involving significant cross-functional interface complexity, risk and cost. Has the ability to evaluate project/program options and to make recommendations that meet overall business objectives. Works with leaders at all levels throughout the company to ensure the success of the program and compliance with all contractual obligations.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

• Serves as Quality Management subject matter expert to the medical and/or behavioral health (BH) programs and executes new strategic quality initiatives designed to support corporate goals including NCQA accreditation
• Provides day-to-day oversight of quality improvement needs in all products and quality requirements
• Chairs the workgroups and committees which oversee progress with all corporate, regulatory, and contractual quality improvement initiatives
• Ensures the Plan meets contractual (e.g. EOHHS, DHHS, EQRO, NCQA and other regulatory/ accreditation bodies) requirements for medical and/or BH related quality improvement projects:

• Develops detailed project plans and timelines for performance improvement project implementations and reviews
• Facilitates large multidisciplinary project teams and smaller sub-teams so that each performance improvement project has appropriate outcome metrics, measures of success, and interventions that are specific to meet expectations
• Generate supporting documentation for new project proposals, including internal and external reports
• Works with clinical/quality, data analytics team and others as needed, to ensure that data needs are identified and incorporated into the process including performing data analysis as needed
• Serves as the liaison with vendors, as appropriate; to incorporate vendor data into assigned regulatory and/or internal reports
• Prepares timely submissions for assigned projects, and responds to regulatory inquiries regarding submissions
• Represents the Plan at state Quality Management meetings as needed

• Solicits internal input in preparation for external meetings
• Coordinates the submission of all regulatory and quality related projects so that they are submitted on time and complete
• Develops and implements a process to utilize internal and external data sources, including quarterly reports, monthly management reports and population studies to identify interventions and potential topics for performance improvement projects initiatives
• Manages day-to-day quality processes including document preparation, literature reviews, and web\xe2\x80\x93search requiring a high degree of independent decision-making
• Regular and reliable attendance is an essential function of the position
• Other duties as assigned

Qualifications:

Education Required:

• Bachelor\xe2\x80\x99s Degree in nursing, health administration or related field or the equivalent combination of training and experience
• Master\xe2\x80\x99s Degree in Social Work, Behavioral Health, Public Health, or related field preferred

Experience Required:

• 5+ years progressive experience in health care / managed care
• In depth knowledge of and experience with clinical quality management and related business goals and practices within related areas preferred
• Experience with Medicaid/Medicare recipients and community services preferred
• Prior experience with NCQA preferred
• Experience in project development and / or health policy preferred
• Lean Six Sigma or CPHQ training preferred

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

*WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.

Required Skills

Required Experience

WellSense Health Plan