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 Manager of Operational Quality Assurance (QA) is responsible for evaluating quality across the Member and Provider Service team to ensure successful performance outcomes. This includes achieving team productivity and quality metrics, responding to related interdepartmental requests, and providing analytical and reporting support on Member and Provider Service quality. The Manager is responsible for developing policies, procedures, and workflows for QA staff. Participates with other members of management to discuss, develop and implement operational and organizational processes that improve efficiency.

Our Investment in You:

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

Key Functions/Responsibilities:

• Works with Director of Member and Provider Service to set direction, establish strategic goals and execute initiatives to support the quality program.
• Leads a team of QA auditors and coaches in their mission to assess and improve operational quality.
• Manages staff development and work standards; recruits, motivates and retains a high caliber of team members to ensure efficient operation of the QA function.
• Responsible for on-going training of the team, including coaching and leading to continuous improvement of operational performance.
• Establishes and maintains standards of performance for productivity, quality and turnaround as necessary. Adjusts such standards when necessary.
• Provides feedback, suggestions, status updates to Member and Provider Service Managers and Supervisors regarding improvement initiatives and opportunities.
• Works with department leadership to review vendor quality, identifying trends and risks.
• Monitors various daily and weekly productivity and quality reports to identify performance gaps.
• Takes corrective action and applies follow through to ensure improvement and goals are achieved.
• Develops and documents workflows, practices and procedures to ensure quality and consistency. Analyzes, updates, and modifies standard operating procedures to support continuous improvement.
• Responsible for the preparation, research of data and records as well as all associated reports required to meet internal and external requirements. Responsible to ensure all monthly required contractual reporting is complete, accurate and timely.
• Generate weekly QA review inventory and manages the completion of audits, daily, weekly and monthly.
• Ensures there is a quality program in place to evaluate the quality of the audits and coaching performed by the quality team, as well as, to calibrate amongst the team and Member and Provider Service leaders.
• Collaborates with department leadership to evaluate quality results, discern trends in errors/discrepancies and identify training and documentation opportunities.
• Maintains quality database systems.
• Maintains regular meeting schedule with QA staff to review procedures as well as identify and resolve issues.
• Coaches and mentors staff to further development and achieve high standards of performance.
• Establishes professional relationships with stakeholders to facilitate the quality process internally and externally.
• Provides continuous review and enhancement of established Member and Provider Service, quality standards.
• Represents department on cross-functional initiatives.
• Understand and promote the mission, vision, and values of WellSense both in the work place and in the community.
• Expected to take on and complete any other assignments outside of the regular duties for this position when assigned by management.

Supervision Exercised:

• Supervises 6-10 staff.

Supervision Received:

• Indirect supervision received weekly.

Qualifications:

Education:

• Bachelor’s Degree or the equivalent combination of training and experience is required.

Experience:

• Five (5) or more years of experience in quality assurance.
• Three (3) years proven leadership experience preferably in quality assurance and/or health plan operations.

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Preferred/Desirable:

• Three (3) years of related managed healthcare or insurance operations experience.
• Quality certification preferred (CPHQ, CQE, CQA, CMQ/OE, etc.).
• Master’s degree in a related field preferred.
• Experience in process redesign/re-engineering.

Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes :

• Excellent management skills of both people and processes.
• Effective collaborative and proven process improvement skills.
• Strong oral and written communication skills; ability to interact within all levels of the organization.
• A strong working knowledge of Microsoft Office products.
• Demonstrated ability to successfully plan, organize and manage projects
• Detail oriented, excellent proof reading and editing skills.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Ability to work OT during peak periods.
• Remote based role with occasional paid travel to Charlestown office for collaboration and innovation meetings.
• No or very limited physical effort required. No or very limited exposure to physical risk.

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.

Required Skills

Required Experience