Medical Management Nurse – Florida

About the role

The Medical Management Nurse will evaluate complex clinical cases to determine medical necessity, using advanced nursing judgment and critical thinking. This fully remote position serves members throughout Florida and supports the organization’s commitment to high‑quality, cost‑effective care.

Key responsibilities

• Review and assess the most challenging member cases, applying clinical guidelines to approve or deny services.
• Collaborate with healthcare providers to clarify clinical information and promote optimal outcomes.
• Provide consultation to the Medical Director on ambiguous or complex cases.
• Serve as a resource for lower‑level nurses and assist with special projects and policy development.
• Participate in cross‑functional teams, process‑improvement initiatives, and discharge planning activities.

Required profile

• Registered Nurse licensed to practice in Florida.
• Demonstrated ability to apply nursing judgment to complex clinical scenarios.
• Strong analytical skills and ability to interpret clinical data.
• Excellent communication skills for interaction with providers and internal teams.

Required skills

• Clinical assessment and nursing judgment.
• Knowledge of medical necessity criteria and healthcare policies.
• Experience with case review and documentation.