Senior Quality Measure Specialist - Registries

Mass General Brigham (Enterprise Services)
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jan 14, 2025
The Mass General Brigham Office of the Chief Medical Officer (OCMO) is seeking a Senior Quality Measure Specialist with expertise in registry-based quality measurement and a commitment to advancing healthcare performance. This role is essential to supporting high-stakes national registry programs that require precise chart abstraction, certification, and compliance with program standards. The Senior Quality Measure Specialist will manage data abstraction, validation, and reporting for key registries such as the Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), Society of Thoracic Surgeons (STS), and the National Surgical Quality Improvement Program (NSQIP), among others. Reporting to the OCMO Quality Program Manager, the Senior Quality Measure Specialist will be a vital member of a cross-functional team, collaborating closely with clinical, analytics, and information technology teams to ensure accurate registry data submission and compliance. This role also involves analyzing performance metrics, providing actionable insights for clinical leaders, and supporting quality improvement initiatives through robust data interpretation. Ideal candidates will have strong project management, data abstraction, and analytical skills, as well as an understanding of healthcare quality standards and registry certification requirements. Principal Duties and Responsibilities: - Lead the chart abstraction process for various national registries such as the Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), Society of Thoracic Surgeons (STS), United Network for Organ Sharing (UNOS), National Surgical Quality Improvement Program (NSQIP) Adult and Pediatrics, and the Commission on Cancer (CoC), ensuring a high degree of accuracy and compliance with registry-specific requirements. - Manage data submission and validation for registry participation, including the preparation and transmission of data files according to each registry's specifications and timelines. - Monitor registry performance metrics and analyze outcomes data to identify trends, areas for improvement, and opportunities to enhance patient care quality within the organization. - Collaborate with clinical teams and department leaders to interpret registry data, provide insights on performance measures, and develop action plans for quality improvement initiatives based on registry findings. - Participate in regular committee meetings (often quarterly) with clinical teams to review registry performance data, discuss findings, and collaboratively identify areas for improvement. Ensure that performance metrics align with registry standards and support the hospital's ongoing quality improvement initiatives. - Stay current with registry updates and changes, including modifications to data elements, abstraction guidelines, and certification requirements, and communicate these changes to relevant stakeholders. - Ensure ongoing compliance with certification and recertification requirements for relevant registries, including scheduling and preparing for certification exams and maintaining necessary documentation. - Serve as the primary representative for registry-related accreditation site visits (e.g., MBSAQIP), demonstrating a comprehensive understanding of registry standards, data abstraction processes, and performance outcomes. Support hospital accreditation efforts by preparing documentation, presenting data, and addressing inquiries from the accrediting body during onsite evaluations every 2-3 years. - Provide training and mentorship to junior abstractors, promoting best practices in data abstraction and adherence to registry protocols, and facilitating inter-rater reliability to ensure consistency across the team. - Coordinate with Information Technology and Electronic Health Record (EHR) teams to optimize data extraction processes, improve data quality, and streamline abstraction workflows. - Prepare and present detailed reports and presentations summarizing registry data, performance outcomes, and recommendations to leadership, clinical staff, and external partners in various formats (narrative summaries, slides, graphs, tables). - Utilize Mass General Brigham values to guide decisions, actions, and behaviors, embodying principles such as Patient-Centered Care, Accountability, Innovation, Diversity & Inclusion, Integrity & Respect, Continuous Improvement, and Teamwork & Collaboration. - Other duties and responsibilities as assigned, contributing to the overall success of the OCMO Analytics team and supporting organizational goals. Bachelor's or master's degree in business, Health Policy, Public Health, or related degree preferred Clinical licensure (RN, NP, PA) preferred. Certification in relevant national registries (e.g., Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), Society of Thoracic Surgeons (STS), United Network for Organ Sharing (UNOS), National Surgical Quality Improvement Program - Adult or Pediatrics (NSQIP), Commission on Cancer (CoC)) required or the ability to obtain and maintain certification within these programs, as applicable. Commitment to ongoing certification maintenance, including annual recertification exams, as required by specific registries to ensure compliance with national standards. 3+ years of experience in healthcare quality measurement, analytics, chart abstraction 3+ years of experience in project management or improvement Proficient with Epic Workbench Reporting and navigating Epic for chart review. Proficiency with Snowflake, SQL, or other analysis language a plus Clinical experience a plus Strong PC skills/Microsoft applications including Word, Powerpoint, Excel are required. Skills/Abilities/Competencies Ability to function effectively and independently in a fast-paced environment, organize and prioritize work independently, and meet tight deadlines Ability to manage multiple projects/registries simultaneously, set priorities, and collaborate with team members and others throughout the organization Possess strong interpersonal skills to effectively communicate with cross functional teams including staff at all levels of the organization Practical problem-solving abilities, i.e. the ability to formulate hypotheses, test options and move forward in a fast-paced environment Ability to coach/teach others about complex quality measures in various registries Excellent interpersonal skills, including strong customer service orientation and the ability to translate complex technical concepts to non-technical audiences. Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.