Senior Director, Operational Quality & Compliance

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 Senior Director brings deep subject matter expertise in healthcare operations and configuration. They lead enterprise-wide operational quality initiatives, compliance strategies, and system implementations that drive accuracy, reduce operational risk, and enhance the member and provider experience. Acting as a critical connector across business, IT, product, and compliance teams, this individual ensures end-to-end traceability, audit readiness, and scalable configuration practices to support growth, transformation, and regulatory change.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Responsibilities:

* Strategic Quality & Compliance Leadership

* Serve as the operational configuration authority on quality, providing leadership across all functions including benefits, claims, enrollment, and member support.

* Drive the development and adoption of enterprise quality frameworks for configuration accuracy, compliance, and operational consistency.

* Function as the senior escalation point for critical configuration issues, ensuring rapid resolution, root cause remediation, and long-term process optimization.

Operational Configuration Governance

* Oversee the translation of complex benefit designs and regulatory requirements into audit-ready, validated configuration specifications.

* Ensure systemic alignment across benefits, claims adjudication rules, member communications, enrollment files, and digital platforms.

* Partner with Compliance and Legal to maintain adherence to CMS, state, and commercial regulatory standards.

System Implementations & Product Launch Readiness

* Lead configuration QA and validation strategies for enterprise system migrations, benefit platform upgrades, and new product launches.

* Oversee UAT execution, defect resolution, data mapping, and crosswalk integrity across key operational systems.

* Collaborate with IT, Product, and Operational leaders to ensure successful, compliant go-lives and seamless member/provider impact.

End-to-End Process Optimization

* Standardize QA methodologies, validation protocols, and cross-functional checkpoints to reduce errors, cycle times, and rework.

* Lead continuous improvement initiatives that streamline benefit configuration workflows and enhance audit traceability.

* Develop scalable tools and processes for operational readiness reviews and cross-functional communication of configuration changes.

Regulatory Documentation & Audit Support

* Own the development and maintenance of operational configuration documentation, including traceability maps, audit logs, and regulatory crosswalks.

* Support internal and external audits through robust documentation and proactive compliance collaboration.

* Ensure configuration records and decisions are transparent, defensible, and aligned with regulatory and contractual obligations.

Data-Driven Decision Making & Performance Monitoring

* Define and track key performance indicators (KPIs) for configuration quality, claims accuracy, and operational defect resolution.

* Utilize analytics and root cause analysis to identify systemic issues, inform decision-making, and drive measurable improvements.

* Report out performance trends and quality metrics to senior leadership, with actionable recommendations.

Supervisory Responsibilities:

* Operates as a senior individual contributor with enterprise-level influence.

* Provides functional leadership and quality oversight across cross-departmental teams and project workstreams without direct line authority.

Qualifications:

* Education:

o Bachelor's degree or equivalent experience required.

o Advanced degree or relevant certifications preferred.

Experience:

* 10+ years of progressive experience in healthcare operations with deep expertise in configuration in operational areas such as claims, benefits, service, and enrollment (e.g., Facets or similar).

* Proven success leading enterprise-wide quality, compliance, or system implementation initiatives in a matrixed environment.

* Strong working knowledge of CMS and state regulatory frameworks and their operational implications.

Core Competencies:

* Strategic thinking and operational execution in highly regulated environments.

* Expert-level understanding of healthcare configuration logic, claims adjudication, and system dependencies.

* Outstanding cross-functional leadership and communication skills.

* High attention to detail with a systems mindset.

* Ability to influence without authority and drive enterprise change through quality advocacy.

Working Conditions:

* Primarily remote with occasional travel to the office for meetings or project work

* Flexible hours required during benefit build cycles, audit periods, and major implementations.

* High collaboration with geographically dispersed teams and stakeholders.

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