Medical Management Nurse - Florida
Core
Review complex medical cases to determine medical necessity of requested services using nursing judgment and critical thinking.
Role type
Senior Utilization Review Nurse (Medical Management)
Builds
Clinical assessments and service approval decisions for health plan members
Domain
Health Insurance / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Nursing judgment, critical thinking, clinical assessment, policy application, case management, discharge planning, quality auditing, process improvement, stakeholder collaboration, training
Preferred skills
Multi-state licensure, experience with complex clinical concepts, cross-functional team participation
Technologies
Clinical guidelines, organizational policies
Responsibilities
Analyze members' clinical information to evaluate medical necessity; Consult Medical Director on complex or unclear cases; Collaborate on discharge planning and equipment needs; Participate in process improvement and quality audit initiatives; Educate members on plan benefits; Train lower-level clinician staff.
Seniority
Mid-Senior level, hands-on IC