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When to Use a Nurse Case Manager

Written by Lisa Lao , a writer for Bloom Magazine 

In the world of workers' compensation claims, the role of nurse case managers can be invaluable in ensuring efficient medical care, cost control, and successful outcomes for injured employees. Unfortunately, many self-insured employers and insurers often leave the decision of when to involve a nurse case manager entirely to the discretion of the claims adjuster. This approach can sometimes lead to delayed intervention and escalating medical costs. To address this issue and make the most of nurse case management services, establishing specific guidelines for their utilization is crucial.

Two Types of Nurse Case Managers

Before diving into when to use nurse case managers, it's essential to understand that there are two primary types: telephonic case managers (TCMs) and field case managers (FCMs). TCMs operate remotely, handling their caseload through telephone, email, fax, and regular mail, while FCMs work directly with injured employees and medical providers in face-to-face meetings.

Criteria for Triggering Nurse Case Manager Involvement

To ensure the timely and appropriate use of nurse case managers, specific criteria should be established. These criteria help identify cases where their expertise can make a significant impact. Common triggers for nurse case manager involvement include:

  1. Immediate hospitalization following an accident.

  2. Amputations of fingers or toes.

  3. Second-degree burns covering a limited skin area.

  4. Electrocution incidents.

  5. Concussions.

  6. Vision impairment.

  7. Immediate loss of hearing.

  8. On-the-job heart attack (if the claim is compensable).

  9. On-the-job stroke (if the claim is compensable).

  10. Injuries such as rotator cuff or other shoulder injuries, meniscus or other knee injuries, ankle sprains, back injuries, neck injuries, joint dislocations, carpal tunnel syndrome, tendonitis, fractures requiring time off work, hernias, asbestosis, pneumoconiosis, and other occupational lung diseases, and occupational skin diseases caused by chemical exposure.

Criteria for Field Case Manager Involvement

While both TCMs and FCMs can handle cases meeting the above criteria, there are situations where the presence of an FCM is particularly beneficial. These include:

  1. Attendance at independent medical examinations.

  2. Accompanying the employee to doctor appointments.

  3. Cases where the employee has been referred to a specialist by the initial medical provider.

  4. Severe injuries such as brain and brain stem injuries, catastrophic injuries, spinal cord damage or severance, amputation of hand, arm, foot, or leg, third-degree burns or burns covering 25% or more of the body, total loss of vision, multiple amputations, multiple traumas from the accident, narcotic addictions, lack of medical improvement during treatment, suspected improper or inadequate treatment, employee non-compliance with doctor's instructions, and employee missing medical appointments.

Maximizing the Benefits

Recognizing the well-established benefits of medical case management, some self-insured employers and insurers are taking the decision on whether or not to involve nurse case managers out of the hands of adjusters. They are mandating the use of medical case management under specific circumstances, such as assigning a nurse case manager to all indemnity claims or having a medical case management company review all reported workers' compensation claims and selecting cases where intervention by either a TCM or an FCM can make a difference.

In summary, the decision of when to use a nurse case manager is a critical one in the world of workers' compensation claims. Establishing clear guidelines based on specific criteria can help ensure that these valuable professionals are involved in cases where their expertise is most needed, leading to better outcomes for injured employees and cost control for employers and insurers. By making informed decisions on nurse case manager involvement, stakeholders can optimize the benefits of medical case management in the complex landscape of workers' compensation claims.

For further guidance on utilizing nurse case managers or choosing between TCMs and FCMs, consider consulting experienced professionals in the field.


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