Quality and Process Improvement Lead

JOB SUMMARY

Serves as the vital bridge between internal operations and our clients, ensuring strict compliance with complex client parameters while safeguarding quality standards. By proactively analyzing audit trends and leading calibration efforts, this role mitigates operational risk, optimizes outcomes, and drives continuous process improvements, including targeted machine learning integration. Ultimately, the position elevates client trust, strengthens internal team capability, and protects organizational revenue through consistent, high-accuracy service delivery.

Mission, Culture & Values

At Dane Street, we believe exceptional employee experiences create exceptional client experiences. Our culture is built on collaboration, continuous improvement, accountability, and care.

We care for our customers, we care for our employees, and we care for one another. Every team member plays an important role in creating an environment where people feel respected, supported, empowered to grow, and inspired to do meaningful work.

What You’ll Do

Quality Calibration and Client Alignment

• Partner directly with client auditors through monthly review calls and calibration sessions to maintain operational alignment, clarify expectations, and minimize scoring variance.
• Manage a monthly case sample selection from reconciliation reports using audit criteria, logging scores and deduction points in the designated client portal.
• Lead the end-to-end audit rebuttal process, investigating findings and presenting timely, data-backed appeals to the client.
• Maintain, analyze, and upload quality metrics and audit insights within the client portal to ensure real-time visibility into compliance trends and team performance.
• Lead in-person client touchpoints and strategic business reviews to strengthen trust, align on evolving compliance standards, and reinforce partner satisfaction.

Team Coaching and Continuous Improvement

• Facilitate regular coaching sessions with the internal QA team to communicate updated client specifications, scoring parameters, and quality standards.
• Analyze audit trends alongside internal leadership to identify root causes of quality gaps and recommend actionable process solutions.
• Oversee post-audit action plans, tracking and driving the implementation of process updates and machine learning (ML) enhancements to measurably improve audit performance.

Process Improvement

• Collaborate with Machine Learning, the client, and operational teams to translate findings and client feedback into actionable automation rules, driving continuous model accuracy and operational efficiency.
• Validate new machine learning automations and tool features against live sample data before full rollout to ensure they meet client quality benchmarks.
• Establish and conduct internal calibration sessions across the QA team to ensure baseline consistency and eliminate scoring variances before reports are client-facing.
• Document new audit methodologies, case guidelines, and client-specific business rules into standardized operating procedures (SOPs) for onboarding and retraining.
• Design Corrective and Preventive Action (CAPA) protocols for recurring high-severity errors or systematic compliance failures.

What Makes This Role Successful:

You’re someone who naturally looks for ways to make things better. You bring a thoughtful, detail-oriented approach to reviewing client cases, with the ability to spot both individual issues and larger patterns or opportunities for improvement.

You’re comfortable asking questions, digging into the “why” behind an issue, and using good judgment to determine what needs to change. You communicate your findings clearly and turn them into practical recommendations that the QA team can use to improve workflows.

You take ownership of your work, collaborate well with others, and are motivated by seeing your insights lead to real improvements in quality, consistency, and the client experience. Most importantly, you don’t just identify what isn’t working—you help find a better way forward.

Requirements

What Your First 90 Days May Look Like:

First 30 Days — Transition, Assess & Establish Baseline

Focus on gaining a comprehensive understanding of the Sedgwick audit lifecycle, mastering monthly case selection criteria, scoring reconciliation methods, rebuttal workflows, and client calibration activities.

Approach the onboarding process through a continuous improvement lens. Using a fresh perspective, conduct a deep dive into recent audit outputs and variance trends as you’re learning to establish a performance baseline, pinpoint root causes for scoring deductions, and surface immediate opportunities for process refinement. As an internal auditor, your insights are critical from day one. You are expected and encouraged to speak up, challenge existing workflows, and highlight areas where we can optimize quality and efficiency.

Days 31–60 — Analyze, Improve & Implement

Transition to full operational ownership of the audit and calibration cycle while pivoting insights into tangible process improvements. Partner closely with PAS leadership and the QA team to dismantle recurring quality bottlenecks through root-cause analysis, tighter internal calibration, and direct coaching interventions. Concurrently, serve as the bridge to technology partners, identifying and championing high-value workflow adjustments and machine-learning enhancements that scale overall efficiency and audit accuracy.

Days 61–90 — Optimize, Measure & Sustain

Shift focus toward measuring business impact and institutionalizing continuous improvement. Validate recent process changes and coaching initiatives by measuring shifts in scoring variance and defect trends. Formalize a repeatable, long-term framework for internal calibration, ongoing QA education, and workflow refinement. Finally, establish a regular reporting cadence for executive leadership, delivering transparent visibility into risk areas, implemented solutions, and measurable performance gains.

EDUCATION/CREDENTIALS:

Associate's Degree or Equivalent Experience

Must Haves:

• Experience in quality assurance, auditing, utilization review, or a related healthcare operations function.
• Working knowledge of workers’ compensation utilization review processes and requirements.
• Ability to interpret and apply client-specific requirements, audit criteria, scoring methodologies, and quality standards.
• Strong working knowledge of evidence-based and jurisdiction-specific clinical guidelines and criteria, including ODG, MTUS, and other applicable state-specific treatment guidelines.
• Strong analytical skills, including the ability to identify trends, investigate discrepancies, and perform root-cause analysis.
• Ability to translate audit findings and data into practical process improvements and corrective actions.
• Experience providing quality feedback, coaching, or education to operational teams.
• Strong written and verbal communication skills, including the ability to communicate effectively with internal leadership and external client partners.
• Strong attention to detail with the ability to independently manage recurring audits, deadlines, documentation, and follow-up activities.
• Proficiency with Microsoft Office and the ability to work effectively with reporting, audit, and case-management systems.
• Ability to collaborate across Operations, Quality, Technology, and other functional teams.
• Ability to travel up to 10%.

Preferred Qualifications:

• 3+ years’ experience working with the client(s) the role will support in a QA function

WORKING CONDITIONS/PHYSICAL DEMANDS:

• Prolonged periods sitting or remaining stationary at a desk and working on a computer.
• Constant operation of a computer, keyboard, mouse, and other digital productivity tools.
• Close visual acuity required to view computer screens, analyze data, and read extensive digital documentation.
• Frequent communication with team members, leadership, and external partners via email, chat, phone, and video conferencing platforms.
• Occasional moving or positioning of office equipment or files weighing up to 10–15 pounds.

Why Join Dane Street?

• Collaborative remote culture
• Professional growth opportunities
• Meaningful work supporting the healthcare industry
• Comprehensive benefits
• Great Place to Work Certified since 2021
• Commitment to employee development

WORK FROM HOME TECHNICAL REQUIREMENTS:

• Supply and support their own internet services.
• Maintaining an uninterrupted internet connection is a requirement of all work from home position.

Equal Opportunity Statement:

At Dane Street, caring for people is at the heart of what we do. We are committed to creating an inclusive workplace where every employee feels respected, valued, and empowered to contribute. We provide equal employment opportunities to all applicants and employees and make employment decisions based on qualifications, merit, business needs, and without regard to race, color, religion, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.

This job description is subject to change at any time.

Benefits

Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace.

ABOUT DANE STREET:

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

Originally posted on Himalayas