WellSense Health Plan
Quality Improvement Manager (Medicaid)
WellSense Health Plan, Boston, Massachusetts, us, 02298
Job Summary
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 Manager is assigned to the New Hampshire and/or Massachusetts contracts and is accountable for clinical quality improvement initiatives that comply with contractual obligations, regulatory requirements, and accreditation standards. The Manager supports process and operational improvements related to clinical initiatives within the Quality Department, oversees quality improvement initiatives by program management involving significant cross‑functional interface complexity, risk, and cost, evaluates project/program options, makes recommendations that meet overall business objectives, and works with leaders at all levels 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
Serve as the Quality Management subject‑matter expert for medical and/or behavioral health programs and execute new strategic quality initiatives designed to support corporate goals, including NCQA accreditation.
Provide day‑to‑day oversight of quality improvement needs in all products and quality requirements.
Chair workgroups and committees that oversee progress with corporate, regulatory, and contractual quality improvement initiatives.
Ensure the Plan meets contractual requirements (e.g., EOHHS, DHHS, EQRO, NCQA and other regulatory/accreditation bodies) for medical and/or behavioral health quality improvement projects:
Develop detailed project plans and timelines for performance improvement project implementations and reviews.
Facilitate large multidisciplinary project teams and smaller sub‑teams so that each performance improvement project has appropriate outcome metrics, measures of success, and interventions specific to meeting expectations.
Generate supporting documentation for new project proposals, including internal and external reports.
Work with clinical/quality, data analytics teams, and others as needed to ensure that data needs are identified and incorporated into the process, including performing data analysis as required.
Serve as the liaison with vendors, as appropriate, to incorporate vendor data into assigned regulatory and/or internal reports.
Prepare timely submissions for assigned projects and respond to regulatory inquiries regarding submissions.
Represent the Plan at state Quality Management meetings as needed.
Solicit internal input in preparation for external meetings.
Coordinate the submission of all regulatory and quality‑related projects to ensure they are submitted on time and complete.
Develop and implement 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.
Manage day‑to‑day quality processes, including document preparation, literature reviews, and web‑search requiring a high degree of independent decision‑making.
Ensure regular and reliable attendance.
Other duties as assigned.
Qualifications Education Required
Bachelor’s Degree in nursing, health administration, or related field, or the equivalent combination of training and experience.
Master’s 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.
Compensation Range $77,000 - $111,500
This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive and considers education, experience, skills, and certifications/licensure as they directly relate to the position. In addition, WellSense offers generous total compensation that includes, but is not limited to, 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.
Note: This range is based on Boston‑area data and is subject to modification based on geographic location.
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 is committed to the diversity and inclusion of staff and their members.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability, or protected veteran status. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees.
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Our Investment In You
Full‑time remote work
Competitive salaries
Excellent benefits
Key Functions / Responsibilities
Serve as the Quality Management subject‑matter expert for medical and/or behavioral health programs and execute new strategic quality initiatives designed to support corporate goals, including NCQA accreditation.
Provide day‑to‑day oversight of quality improvement needs in all products and quality requirements.
Chair workgroups and committees that oversee progress with corporate, regulatory, and contractual quality improvement initiatives.
Ensure the Plan meets contractual requirements (e.g., EOHHS, DHHS, EQRO, NCQA and other regulatory/accreditation bodies) for medical and/or behavioral health quality improvement projects:
Develop detailed project plans and timelines for performance improvement project implementations and reviews.
Facilitate large multidisciplinary project teams and smaller sub‑teams so that each performance improvement project has appropriate outcome metrics, measures of success, and interventions specific to meeting expectations.
Generate supporting documentation for new project proposals, including internal and external reports.
Work with clinical/quality, data analytics teams, and others as needed to ensure that data needs are identified and incorporated into the process, including performing data analysis as required.
Serve as the liaison with vendors, as appropriate, to incorporate vendor data into assigned regulatory and/or internal reports.
Prepare timely submissions for assigned projects and respond to regulatory inquiries regarding submissions.
Represent the Plan at state Quality Management meetings as needed.
Solicit internal input in preparation for external meetings.
Coordinate the submission of all regulatory and quality‑related projects to ensure they are submitted on time and complete.
Develop and implement 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.
Manage day‑to‑day quality processes, including document preparation, literature reviews, and web‑search requiring a high degree of independent decision‑making.
Ensure regular and reliable attendance.
Other duties as assigned.
Qualifications Education Required
Bachelor’s Degree in nursing, health administration, or related field, or the equivalent combination of training and experience.
Master’s 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.
Compensation Range $77,000 - $111,500
This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive and considers education, experience, skills, and certifications/licensure as they directly relate to the position. In addition, WellSense offers generous total compensation that includes, but is not limited to, 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.
Note: This range is based on Boston‑area data and is subject to modification based on geographic location.
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 is committed to the diversity and inclusion of staff and their members.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability, or protected veteran status. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees.
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