Quality Measure Specialist - Surgical Registries

Site: Massachusetts General Physicians Organization, Inc.

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Job Summary

Job Summary

The Massachusetts General Hospital is seeking a 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 Quality Measure Specialist will manage data abstraction, validation, and reporting for key surgical registries such as the Pediatric National Surgical Quality Improvement Program (Pedi NSQIP), Adult NSQIP, Trauma Registry, Burn Care Quality Platform (BCQP), and Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), among others.

Reporting to the Senior Program Manager of Quality and Safety, the 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 Pediatric and Adult National Surgical Quality Improvement Program (NSQIP),Trauma Registry, Metabolic and Bariatric Surgical Quality Improvement Program (MBSAQIP), Society of Thoracic Surgeons (STS), Vascular Quality Initiative (VQI), Burn Care Quality Platform (BCQP) , 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.

- 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 Department of Surgery Quality and Safety Team and supporting organizational goals.

 

Qualifications

• Bachelor’s degree in business, Public Health, or related degree preferred
• Can this role accept experience in lieu of education requirements? Yes
• 2-3 years Experience working with healthcare quality data required
• 2-3 years Experience in project management or improvement required

Skills/Abilities/Competencies

• Commitment to ongoing certification maintenance, including annual recertification exams, as required by specific registries to ensure compliance with national standards.

• Proficient with Epic Workbench Reporting and navigating Epic for chart review.

• Proficiency with Snowflake, SQL, or other analysis language a plus

• Clinical experience is a plus

• Strong PC skills/Microsoft applications including Word, Powerpoint, Excel are required.

• 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.

Physical Requirements

• Sitting Constantly (67-100%)
• Standing Occasionally (3-33%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)

Hybrid

165 Cambridge Street

24

Regular

Day (United States of America)

Pay Range

$79,560.00 - $115,720.80/Annual

Grade

7

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

1300 Massachusetts General Physicians Organization, Inc. is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

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