When to Use a Nurse Case Manager in Workers’ Compensation Claims
In the complex world of workers’ compensation, nurse case managers play a critical role in ensuring timely medical care, controlling costs, and supporting positive outcomes for injured employees. Yet, for many self-insured employers and insurers, the decision of when to involve a nurse case manager is often left solely to the claims adjuster. While adjusters are essential to the process, this approach can sometimes result in delayed intervention—leading to prolonged recovery and escalating medical expenses.
To truly maximize the value of nurse case management, employers and insurers benefit from establishing clear, consistent guidelines that define when these professionals should be engaged.
Understanding the Two Types of Nurse Case Managers
Before determining when to involve a nurse case manager, it’s important to understand the two primary types used in workers’ compensation cases.
Telephonic Case Managers (TCMs) work remotely, managing cases through phone calls, email, fax, and written correspondence. They focus on care coordination, communication, and monitoring treatment progress from a distance.
Field Case Managers (FCMs) work directly in the field, meeting face-to-face with injured employees and medical providers. Their hands-on presence allows for deeper involvement in complex or high-risk cases.
Both types provide value, but their roles differ depending on the nature and severity of the claim.
When to Trigger Nurse Case Manager Involvement
Establishing predefined criteria helps ensure nurse case managers are brought in early—when they can have the greatest impact. Common triggers for nurse case manager involvement include:
Immediate hospitalization following an accident
Amputations of fingers or toes
Second-degree burns covering a limited area
Electrocution incidents
Concussions
Vision impairment or immediate hearing loss
Compensable on-the-job heart attacks or strokes
Musculoskeletal injuries such as shoulder or rotator cuff injuries, knee or meniscus injuries, ankle sprains, back and neck injuries, joint dislocations, carpal tunnel syndrome, and tendonitis
Fractures requiring time off work
Hernias
Occupational illnesses such as asbestosis, pneumoconiosis, other occupational lung diseases, and chemical-related skin conditions
These scenarios often benefit from early clinical oversight, coordinated care, and consistent communication—all areas where nurse case managers add significant value.
When a Field Case Manager Is Especially Beneficial
While many cases can be effectively managed by telephonic case managers, certain situations call for the in-person involvement of a field case manager. These include:
Attendance at independent medical examinations
Accompanying injured employees to physician appointments
Cases involving referrals to specialists
Severe or catastrophic injuries, including brain or spinal cord injuries
Major amputations or multiple traumatic injuries
Third-degree burns or burns affecting 25% or more of the body
Total vision loss
Suspected narcotic dependency
Lack of medical improvement during treatment
Concerns about improper or inadequate care
Employee non-compliance with treatment plans or missed appointments
In these cases, the presence of a field case manager can help ensure appropriate care, identify issues early, and keep claims from derailing.
Maximizing the Benefits of Nurse Case Management
Recognizing the proven benefits of medical case management, some employers and insurers are taking a more proactive approach. Instead of leaving the decision entirely to adjusters, they are implementing structured policies—such as assigning nurse case managers to all indemnity claims or requiring medical case management companies to review every reported claim and recommend whether a TCM or FCM should be involved.
This structured approach helps ensure consistency, earlier intervention, and better utilization of clinical expertise.
A Strategic Decision with Real Impact
Deciding when to use a nurse case manager is a strategic choice that directly affects outcomes in workers’ compensation claims. Clear guidelines based on defined criteria help ensure these professionals are involved where they can make the greatest difference—supporting injured employees, improving recovery timelines, and controlling costs for employers and insurers.
With informed decision-making and proactive planning, nurse case management becomes not just a support function, but a powerful tool in navigating the complexities of workers’ compensation claims.
