Role of the Nurse Case Manager in Workers Compensation Claims

The goal of the Nurse Case Manager (NCM) is to assist the injured employee and facilitate the employee’s return to work through the identification of the medical services needed, the arrangement for those services to be provided, to advocate for the employee’s medical needs through communication with all medical providers, and to educate the employee on the employee’s role in the recovery process.

The NCM can be employed by the workers’ compensation insurance carrier, the self-insured employer, the third party administrator or by the medical provider, such as an orthopedist. For the purpose of this blog, we will review the role of the NCM from the perspective of the workers’ comp insurance carrier.

The title of Nurse Case Manager is the most frequently used name for the role, but like workers’ comp adjusters are sometimes referred to as claim examiners, there are other names for the NCM. In some insurance companies the role is referred to as the “workers compensation case manager” or “injury management facilitator” or “field case manager” (FCM) if most of the work is done away from the office, or “telephonic case manager” (TCM) if the work is done in the office by using the telephone. (WCxKit)

Note: These are NOT the same as NURSE TRIAGE which is when a claim is reported directly to an RN for suggestions about initial medical treatment.

Nurse Case Manager is an Experienced Nurse

The NCM is a trained nurse, either a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) before entering the NCM field. Most workers compensation insurance carriers hire experienced NCMs from other areas of the medical field, for instance from a health maintenance organization. The insurance carrier can teach the NCM the basics of workers compensation to which the NCM will add her knowledge of medical management.

It is normal for the NCM of an insurance carrier to have experience in occupational health, medical management, discharge planning and home health care. The role of the NCM is to combine these disciplines to facilitate the employee’s return to work in the minimum amount of time without reducing the quality of the medical care. The NCM is a skilled communicator as she is constantly in contact and working with the employees and the medical provider.

The NCM can be brought into the workers’ comp claim at any point in the life of the claim. Normally, it is the adjuster who determines whether or not an NCM will be utilized on a workers comp claim, but the employer can and should request an NCM if they feel the employee would benefit from the utilization of an NCM.

Different Insurance Carriers Utilize NCM in Different Ways

Different insurance carriers utilize the NCM in different ways. Some insurance carriers rely heavily on a TCM who contacts all parties by telephone, fax or letter. To function as a TCM, the nurse must have excellent telephone skills and interpersonal skills, along with a very in-depth clinical background knowledge. The caseload assigned to a TCM is larger than the caseload assigned to an FCM as the TCM does not have the travel time.

Other insurance carriers prefer to use a FCM. The FCM is often referred to as on-site nurse, as the work is done in person by appointments with the employee, the employer, the medical providers and other vendors. The FCM must have strong interpersonal skills and be able to establish a good rapport with all the parties involved in the medical care. The caseload is lighter than the TCM due to t travel time to appointments.

Many workers compensation insurers use both a TCM and FCM. The TCM is utilized to handle the simpler or less severe workers’ comp claims. The FCM is utilized on the severe or complex workers comp claims where the on-site case management will be the most beneficial.

Nurse Case Manager Makes Separate Three-Point Contact

The NCM, whether a TCM or FCM, works in conjunction with the claims adjuster. The NCM makes a separate three-point contact (employee, employer, medical provider) from the three-point contact made by the adjuster, as the NCM has a different perspective than the adjuster has in the management of the workers comp claim.

When the NCM makes three-point contact, it is for the purpose of introducing himself/herself and obtaining an understanding of the nature and severity of the claim. The initial contacts assist the NCM in establishing rapport and creating a working relationship with the employee, employer and medical provider(s). It is most beneficial to the employee to know a medical professional will be there to assist them throughout the workers comp process.

The initial interviews also assists the NCM with the initial assessment, coordination, planning and evaluation of the injury and the necessary medical treatment. In conjunction with the medical provider(s) the NCM will formulate a treatment plan. The NCM is then able to determine what barriers exist that would prevent the employee from returning to work. The NCM educates the employee on the benefits of returning to work quickly and facilitates with the employer the accommodations necessary to meet the medical concerns of the physician.

It often takes several contacts with the three parties (employee, employer, medical provider) to coordinate the employee’s timely and successful return to work. The more complex or severe the injury, the more times the NCM must be in contact with these three parties. The NCM continues to evaluate the employee’s progress and monitors the treatment until the employee is released to return to work.

Nurse Case Management Offers Many Benefits

The benefits provided by the NCM are many. The return on investment is such that many insurance carriers have shifted from the adjuster bringing the NCM into the claim when needed to an approach of early intervention. Each new workers comp claim is reviewed by a NCM. This allows the NCM to direct and control the medical care from the beginning, preventing many workers comp claims from getting on a treatment track that delays the employee’s recovery and return to work.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

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