Cardiac Nurse Case Manager

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Orlando, FL

Reporting To: Amber Dudney

Compensation: $78,000 - $85,000 / year

Description

Key Responsibilities

• Provide telephonic nurse case management services for complex cardiac and cardiovascular workers' compensation claims involving Florida first responders. 
• Assess, coordinate, and monitor medical treatment related to cardiac diagnoses, including but not limited to myocardial infarction, coronary artery disease, hypertension-related cardiac conditions, arrhythmias, cardiomyopathy, heart failure, and other cardiovascular disorders. 
• Facilitate communication among injured workers, employers, adjusters, attorneys, medical providers, rehabilitation professionals, and client representatives to ensure coordinated and efficient claim resolution. 
• Serve as a clinical liaison for client accounts, building and maintaining strong professional relationships through proactive communication and exceptional customer service. 
• Participate in weekly client claims review meetings to discuss claim status, treatment progression, barriers to recovery, cost drivers, litigation concerns, return-to-work opportunities, and recommendations for future claim handling. 
• Prepare and present clinical summaries, action plans, and recommendations for client review meetings. 
• Evaluate the medical necessity, appropriateness, and effectiveness of treatment plans using evidence-based medicine, Florida Workers' Compensation guidelines, and relevant cardiac care standards. 
• Conduct comprehensive clinical assessments and develop individualized case management plans based on medical records, provider communications, and injured worker interviews. 
• Identify barriers to medical recovery, claim resolution, and return-to-work outcomes, and develop strategies to address those barriers. 
• Monitor treatment adherence, provider performance, and clinical outcomes to promote quality care and cost containment. 
• Review cardiac diagnostic testing, specialist consultations, medications, procedures, hospitalizations, rehabilitation services, and treatment recommendations. 
• Collaborate with treating physicians and specialists to ensure treatment plans support optimal recovery and functional improvement. 
• Provide ongoing education to injured workers regarding their cardiac condition, treatment plan, lifestyle modifications, medications, and recovery expectations. 
• Ensure all clinical documentation is accurate, timely, and compliant with state regulations, client requirements, and company standards. 
• Maintain comprehensive case notes, treatment summaries, and action plans within the claims management system. 
• Proactively manage claims using appropriate case management tools and resources to achieve favorable medical and financial outcomes. 
• Identify situations requiring utilization review, peer review, medical director consultation, independent medical examinations, or additional clinical interventions. 
• Monitor claim progression and recommend appropriate referrals for vocational rehabilitation, functional capacity evaluations, specialty services, or alternative treatment options when indicated. 
• Evaluate return-to-work capabilities and restrictions in collaboration with treating physicians and employers when medically appropriate. 
• Advocate for quality patient care while balancing regulatory compliance, client expectations, and cost-effective claim management. 
• Participate in quality assurance initiatives, client service activities, and departmental improvement efforts. 
• May assist in training claims professionals and clinical staff regarding cardiac claims management, Florida presumptive legislation, and complex medical issues. 
• May provide mentorship and clinical guidance to less experienced case management staff. 

Skills, knowledge & expertise

• Extensive knowledge of cardiac and cardiovascular conditions, treatment protocols, and recovery expectations.
• Strong understanding of Florida Workers' Compensation regulations, including presumptive claims applicable to first responders.
• Knowledge of Florida Heart/Lung Bill provisions and their impact on claim management preferred.
• Ability to analyze complex medical records and formulate effective clinical recommendations.
• Demonstrated ability to build trusted relationships with clients, adjusters, attorneys, providers, and injured workers.
• Strong presentation and communication skills with the ability to effectively discuss claims during client review meetings.
• Excellent critical thinking, clinical assessment, and problem-solving abilities.
• Strong organizational and time management skills.
• Ability to work independently while managing multiple complex claims.
• Proficiency with claims management systems, electronic medical records, and Microsoft Office applications.
• Excellent written and verbal communication skills.
• Commitment to exceptional customer service and client satisfaction.

• Current Registered Nurse (RN) license in good standing; compact license preferred.
• Minimum of three (3) years of clinical nursing experience in one or more of the following areas:
  • Cardiology
  • Critical Care/ICU
  • Coronary Care Unit (CCU)
• Emergency Department
• Occupational Health
• Medical-Surgical Nursing
• Case Management
• Minimum three (3) years of Workers' Compensation case management experience.
• Experience managing cardiac, cardiovascular, or other complex medical claims preferred.
• Certification in Case Management (CCM) preferred.
• Experience working with public sector accounts, municipalities, first responder populations, or Florida workers' compensation claims strongly preferred.

• This position is highly client-facing and requires regular interaction with employer clients, claim stakeholders, and account leadership.
• Participation in recurring weekly client claims review meetings is required.
• Occasional travel for client meetings, provider visits, training, or account support may be required.
• Smoke-free workplace.

Equal Employment Opportunity & Legal Notices

• Medical, dental, and vision plans to support your health and that of your family
• A 401(k) plan with employer matching
• Time‑off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non‑exempt employees
• Paid holidays
• Life insurance and short‑term and long‑term disability coverage

• Maintain regular and dependable attendance.
• Be available and able to perform job responsibilities during established work hours.