Quality Review Nurse

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

Quality Review Nurse

PRIMARY PURPOSE: To monitor team and colleague technical and quality activities with a focus on trends and quality compliance; to recommend office needs for training to management; to plan and initiate appropriate actions facilitating overall office performance, development and improvement; and to uphold quality initiatives ensuring that the clinical work product meets regulatory, jurisdictional, case management and company Best Practice requirements.

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES  

• Responsible for auditing, tracking/trending audit results, and development and delivery of training to correct deficiencies.

• Audits file actions of individual nurses; delivers individual file results and summary results to the clinical Team

• Lead and recommends training and improvement activities needed to meet service expectations.

• Conducts medically related vendor and client requested audits as requested.

• Prepares reports reflecting national scores and trends.

• Assists with coordinating and implementing national quality initiatives.

• Delivers training for improvements or new policies/procedures.

• Provides management with objective colleague quality measurements for use in colleague development.

• Assists Managed Care and Sedgwick University to maintain case management standards, procedures, policies and jurisdictional regulations.

• Delivers Quality Program training for newly hired nurses; conducts educational calls with individual nurses and their respective supervisor.

Education & Licensing

Bachelor's degree in Nursing (BSN) from an accredited college or university preferred. RN license required. Professional certification such as CCM or CDMS preferred.

Experience

Six (6) years of related line of business experience in telephonic case management (TCM) and/or utilization review or equivalent combination of education and experience required.

Skills & Knowledge

• Thorough knowledge of Managed Care practices and procedures

• Strong understanding of quality and auditing processes

• Good adult learning skills

• Excellent oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Leadership, management, and motivational skills

• Analytical and interpretive skills

• Strong organizational skills

• Excellent interpersonal skills

• Excellent negotiation skills

• Ability to work in a team environment

• Ability to meet or exceed Performance Competencies

TAKING CARE OF YOU BY

• Seeks innovative customer solutions

• Seeks ongoing learning as a professional and a person

• Thrives when solving challenging problems

• Seeks clear role expectations

• Metrics/policies/processes are helpful

• Seeks to contribute to a larger purpose

• Thrives when everyone is working towards same vision/goals

• Strong team and customer service orientation

• Three Medical, and two dental plans to choose from.

• Tuition reimbursement eligible.

• 401K plan that matches 50% on every $ you put in up to the first 6% you save.

• 4 weeks PTO your first full year.

NEXT STEPS

If your application is selected to advance to the next round, a recruiter will be in touch.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $77,500-$81,500. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

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Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.