Quality and Process Improvement Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the link between internal operations and clients, ensuring adherence to client specifications and quality benchmarks.

• Collaborate with client auditors through monthly review calls and calibration meetings.

• Oversee the selection of monthly case samples, score logging, and deduction-point tracking within the client portal.

• Lead audit rebuttals by examining findings and presenting data-supported appeals.

• Maintain, analyze, and upload quality metrics and audit insights onto the client portal.

• Conduct in-person client meetings and strategic business reviews.

• Facilitate coaching sessions for the internal Quality Assurance team.

• Analyze audit trends, identify underlying issues, and propose process improvements.

• Manage post-audit action plans and the execution of process updates and machine-learning enhancements.

• Collaborate with Machine Learning, client, and operations teams to establish automation rules.

• Validate machine-learning automations and tool functionalities against live sample data.

• Organize internal QA calibration sessions to eliminate scoring discrepancies.

• Document audit methodologies, case guidelines, and client-specific regulations in Standard Operating Procedures (SOPs).

• Develop Corrective and Preventive Action (CAPA) protocols for recurring high-severity errors and compliance failures.

• Establish a reporting schedule for executive leadership that includes risks, solutions, and performance improvements.

⛳️ Requirements

• Associate's Degree or Equivalent Experience.

• Background in quality assurance, auditing, utilization review, or a related healthcare operations area.

• Familiarity with workers’ compensation utilization review processes and requirements.

• Ability to interpret and implement client-specific requirements, audit criteria, scoring methods, and quality standards.

• Strong understanding of evidence-based and jurisdiction-specific clinical guidelines and criteria, including ODG, MTUS, and other relevant state-specific treatment guidelines.

• Excellent analytical abilities, including trend identification, discrepancy analysis, and root-cause investigation.

• Capability to convert audit findings and data into actionable process enhancements and corrective measures.

• Experience in providing quality feedback, coaching, or education to operational teams.

• Exceptional written and verbal communication skills.

• Keen attention to detail and ability to independently manage recurring audits, deadlines, documentation, and follow-up tasks.

• Proficient in Microsoft Office and reporting, audit, and case-management systems.

• Ability to work collaboratively across Operations, Quality, Technology, and other functional teams.

• Willingness to travel up to 10%.

• Over 3 years of experience working with the client(s) the role will support in a QA capacity (preferred).

• Must be able to provide and support personal internet services for remote work.

• An uninterrupted internet connection is required for work from home.

🏝️ Benefits

• Medical, dental, and vision coverage for employees and their families.

• Voluntary life insurance options for employees, spouses, and children.

• Voluntary plans for hospital indemnity, critical illness, accident indemnity, and pet insurance.

• Basic life insurance provided at no cost.

• Short-term disability coverage offered at no cost.

• Long-term disability coverage available at no cost.

• Generous paid time off policy.

• 401(k) plan with company matching contributions.

• Apple equipment provided for remote workspaces.

• Media stipend available for remote workspaces.

• Supportive collaborative remote culture.

• Opportunities for professional growth.

• Comprehensive benefits package.

• Commitment to employee development.