Clinical Quality Management Specialist II (Remote) 2026-1465

Overview

Are you interested in empowering and sustaining positive and measurable differences in the health of individuals? Does the thought of joining a team of exceptionally talented quality specialists inspire you? Do you enjoy using your excellent analytical and writing skills to ensure client requirements are met by the consistent, reliable execution of work? Do you thrive in performing audits to ensure performance metrics are met and high-quality care is sustained? We believe in helping those with work-sustained illnesses and injuries to live their best life by providing case management and support to workers, providers, employers, and claims staff.

As a Clinical Quality Management (QM) Specialist II, you will work remotely in your home office from Monday to Friday, 8AM - 5PM Eastern Time and be responsible for supporting the SGS Quality Management System and the activities of the SGS Quality Improvement committees. This role involves supporting the Clinical Operations teams to ensure compliance with QMS and client contracts. The Clinical QM Specialist II identifies requirements and creates processes to ensure consistent and reliable execution of work. They coordinate the creation of controlled documents such as Standard Operating Procedures and Work Instructions, perform audits to meet performance metrics, and address internal and client concerns. Additionally, the Clinical QM Specialist II tracks and mitigates risks, facilitates continual improvement by leading improvement projects, and supports contract managers and the analytics team in preparing quality assurance reports.

Clinical Quality Management Specialist II Responsibilities

• Supports the Clinical Operations Team serving as a clinical resource for all program business units for quality assurance, clinical escalation and training.
• Performs clinical document reviews, identifies deficiencies, errors and collaborates with clinical professionals on remediation.
• Work with internal partners, such as Training, Program Management, Case Management, Analytics, and Information Technology, to bring creative solutions to meet corporate goals, and achieve client requirements.
• Work with external stakeholders and clients to ensure contract requirements and program quality management activities are successfully carried out.
• Collaborate with SGS managers and teams regarding analysis, updates, and recommendations for modifications for procedures and processes to continually improve operations and protocols.
• Assist with the collection and summary of data in collaboration with SGS Quality Committees, identify opportunities for improvement, and present findings.
• Understands each contract's clinical quality assurance requirements and monitors compliance, in collaboration with the SGS, clinical leadership, analytics and management teams.
• Monitors and analyzes clinical outcomes in relation to goals and contractual requirements, in collaboration with the SGS analytics and management team.
• Supports standard and ad hoc audits, as directed by clinical leadership quality committees.
• Provides feedback and coordination of improvement of quality tools, such as job aids, work instructions, and audit checklists.
• Assists in the identification of program deficits and coordinates team training and monitoring of corrective actions.
• Deploys and oversees performance improvement activities.
• Tracks client complaints and issues to resolution, in collaboration with Manager.
• Identifies new areas that need quality monitoring, on a short-term or continuous basis.
• Assists in activities to prioritize improvement initiatives.
• Assumes responsibility for related duties as required or assigned.

Clinical Quality Management Specialist II Qualifications

• Associate’s Degree in Nursing (ADN) required; Bachelor’s degree in Nursing (BSN), Healthcare, Health Administration or a related field preferred.
• Hold a current, active unrestricted Registered Nurse, licensed in any state, Compact License Preferred.
• 5 years related clinical experience with a minimum of 2 years adult medical/surgical nursing experience and a minimum of 2 years case management experience in the workers’ compensation arena OR have a minimum of 1 year of adult medical/surgical nursing experience and 3 years of case management experience in the workers’ compensation arena.
• At least 2 years' experience with Quality Management including project management, quality improvement, corrective action, auditing, and/or staff education.
• Experience with Federal Employee Compensation Act (FECA) and FECA-related issues preferable, as applicable.
• Nationally recognized Quality-related professional certification such as Certified Professional Healthcare Quality or Six Sigma (preferred) OR National certification in case management or related field preferred in one of the following areas: Occupational Health (COHN); Case Management (CCM), Insurance Rehabilitation (CIRS/CRRN), Disability Management (CDMS), and/or Nurse Case Manager Board Certified (ANCC/ANA) preferred.
• Experience with quality-related certification/accreditation such as ISO 9001-2015 Quality Management System or URAC.
• Experience in Workers' Compensation, Disability Management, or related industrial health environment (preferred).
• Ability to pass a preliminary credit and background check.

For a career path that is both challenging and rewarding, join Sedgwick Government Solution’s talented team. Taking care of people is at the heart of everything we do. Our clients depend on our talented colleagues to take care of their most valuable assets—their employees, and their customers. At Sedgwick Government Solutions, caring counts®. Join our team of creative and caring people of all backgrounds and help us make a difference in the lives of others.

Sedgwick Government Solutions 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 a specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is ($63K-$80K). 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.

To be considered for this position, please submit a resume, and complete the application.

The information provided above has been designed to indicate the general nature and level of work of the position. It is not a comprehensive inventory of all duties, responsibilities, and qualifications required.

Important Information

Successful candidates will be required to undergo a financial and criminal background check and obtain and maintain confidential-level security clearance upon hire. We participate in the United States Federal Government E-Verify program to confirm the employment authorization of the employee upon hire.

Search Firm Representatives

Please be advised that Sedgwick Government Solutions is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, a valid written agreement and task order must be in place before any resumes are submitted to Government Solutions. All resumes submitted by search firms to any employee at Government Solutions without a valid written agreement and task order in place will be deemed the sole property of Government Solutions and no fee will be paid in the event that person is hired by Government Solutions.

Government Solutions strives to make our career site accessible to all users. If you need a disability-related accommodation for completing the application process, please contact Government Solutions regarding accommodations.

Sedgwick Government Solutions is an Equal Opportunity and Affirmative Action Employer

All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, disability, marital status, national origin, race, religion, sex, sexual orientation, gender identity, veteran status, or any other classification protected by federal state or local laws as appropriate, or upon the protected status of the person’s relatives, friends or associates.

Sedgwick Government Solutions abides by the requirements of41 CFR 60-741.5(a). This regulation prohibits discrimination against qualified individuals on the basis of disability and requires affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified individuals with disabilities.

Sedgwick Government Solutions abides by the requirements of 41 CFR 60-300.5(a). This regulation prohibits discrimination against qualified protected veterans and requires affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified protected veterans.

About Sedgwick Government Solutions

Sedgwick Government Solutions is a trusted partner for federal agencies across the U.S., helping them confidently manage risk and claims. With decades of experience and deep regulatory expertise, we keep agencies compliant while improving their workforces’ health and productivity. Backed by the most advanced technology, our tailored solutions help agencies navigate the complexities of federal risk and claims management. Sedgwick Government Solutions

Compensation details: 63000-80000 Yearly Salary

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