Quality Improvement Manager (Medicaid)

It's 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.

Job Summary:

The Quality Improvement Manager is responsible for leading and coordinating quality improvement initiatives across the health plan to ensure compliance with regulatory and accreditation standards, improve member outcomes and promote a culture of continuous quality improvement. This role collaborates with key stakeholders at all level and involves strategic planning, data analysis and oversight of quality and performance improvement projects.

Our Investment in You:

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

Key Functions/Responsibilities:

• Develop and implement quality improvement strategies aligned with organizational goals and regulatory requirements (e.g., NCQA, CMS, state regulators).
• Analyze clinical and operational data to identify trends, gaps, and opportunities for improvement.
• Lead root cause analyses and corrective action planning for identified issues.
• Monitor and report on key performance indicators (KPIs), including state specific quality measures, HEDIS and CAHPS.
• Keep current with industry trends, regulatory changes, and best practices in healthcare quality.
• Build strong relationships and collaborate with provider groups to review performance data, identify barriers, and implement targeted interventions to improve quality performance.
• Supports accreditation and compliance activities, coordinating submission requirements and ensuring timely and accurate submission of required reports to regulatory and accrediting bodies.
• Ensure compliance with all contractual and regulatory requirements for medical and/or BH related quality improvement projects:
• Create detailed project plans and timelines for implementing and reviewing performance improvement project.
• Lead workgroups, facilitate large multidisciplinary project teams and collaborate with key stakeholders to develop targeted interventions and drive quality improvement initiatives
• Collaborates with external vendors on quality improvement projects, monitoring vendor performance
• Actively participates in state Quality meetings, collaborating with state leaders and other health plan associates on quality improvement initiatives
• Performs literature reviews to support quality improvement initiatives
• Perform other duties as assigned

Education Required:

• Bachelor's Degree in nursing, health administration, behavioral health, public health or related field (Master's preferred)
• CPHQ, Lean Six Sigma or Project Management certification strongly preferred

Experience Required:

• Minimum 5 years of experience in healthcare quality improvement, preferably within a health plan.
• Strong knowledge of managed care regulations, NCQA accreditation standards, HEDIS measures, and CMS Stars
• Proficiency in data analysis and insights
• In-depth knowledge of quality improvement methodologies and performance measurement tools
• Excellent communication, leadership, and project management skills.
• 5+ years progressive experience in health care or managed care
• Demonstrated ability to lead cross-functional teams and large-scale projects
• Experience working with providers 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 a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. 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