Unsung Heroes: Spotlight on Nurse Case Managers

In this MEC Connect Expert Insights episode, “Unsung Heroes: Spotlight on Nurse Case Managers,” MEC’s Medical Management Consultant Dana Dorsey explains how nurse case managers serve as the critical bridge between injured workers and successful recovery.

Based on two decades of experience in the field, Dana shares insights about how Nurse Case Managers play a vital role in facilitating collaboration between injured workers, employers, healthcare providers, and insurance carriers. This includes:

• Conducting comprehensive evaluations to identify recovery barriers
• Formulating action plans to overcome them and develop return-to-work strategies.
• Mitigating attorney involvement through consistent communication with injured workers.
• Interpreting medical information, educating injured workers, and ensuring necessary treatments.
• Assistance with claims involving wage loss, multiple injuries, catastrophic conditions, non-compliant workers, and surgical recommendations.      

Listen now to gain a fresh perspective on the often underappreciated yet high-impact role Nurse Case Managers play in all aspects of effective workers compensation management.

Chapters

• 0:00 Introduction to Expert Insights Series

Transcript

Sara Hance: 0:04

Hello, this is MEC Connect Expert Insights, a companion series to our main MEC Connect podcast for Midwest Employers Casualty. I'm Sara Hance and in these Expert Insights episodes you'll hear from subject matter experts as they share practical tips and strategies on a variety of topics related to workers' comp and claims management. On a variety of topics related to workers' comp and claims management. Today, dana Dorsey, Medical Management Consultant, will discuss the role of a nurse case manager.

Dana Dorsey: 0:32

Now, let's hear from Dana. Today, I want to share my experience working with nurse case managers. As well as working as a nurse case manager for 23 years, I have found that nurse case managers play an important role in the claims process and help to reduce the cost of a claim. Engaging a nurse case manager helps to minimize delays and ensure that the injured worker receives the necessary care promptly, which generally results in early return to work and better recovery outcomes. The nurse case manager's role is to evaluate the recovery needs of the injured worker, as well as identify barriers to recovery, whether medical, vocational, psychosocial or situational, and formulate an action plan to overcome these barriers. Situational and formulate an action plan to overcome these barriers. The nurse case manager confirms the availability of light duty with the insured and develops a return-to-work plan, again facilitating early return to work. He or she attends scheduled appointments and ensures the physician is informed of all factors that can affect the injured worker's recovery and that he or she is aware of the employer's ability to accommodate light duty. One of the benefits of the nurse case manager attending the appointments is that he or she can provide an update to the TPA and the employer the day of the appointment. This eliminates waiting on the provider's report to determine what treatment was recommended and helps to avoid delays with obtaining authorization and scheduling diagnostic testing, physical therapy, referrals to specialists, etc. The nurse case manager assesses and interprets medical information for factors that might impact a file example prior injuries or surgeries to the injured body part or pre-existing conditions that may delay or slow the recovery process. He or she educates the injured worker on their medical condition, treatment and what to expect, including anticipated return to work timeframes. The nurse case manager informs the injured worker of his or her options and makes sure his or her individual needs are met effectively and efficiently. The nurse case manager evaluates treatment recommendations for relatedness, medical necessity and explores more cost-effective alternatives if indicated and allowed per the state's workers' compensation statutes and guidelines. The injured worker receives the necessary care promptly and assists with hospital discharge planning to include coordinating transfers to inpatient rehabilitation facilities or discharge to home, ordering DME supplies or equipment from preferred vendors, scheduling outpatient therapy and follow-up appointments.

Dana Dorsey: 3:38

The nurse case manager also attempts to avoid attorney involvement by maintaining frequent communication with the injured worker. This allows for increased lines of communication and provides the opportunity to make sure the injured worker understands their medical options and the workers' compensation process process. Some motivators for attorney involvement may include no contact by the employer or the insurer, seeing lawyer advertising or solicitation, unpaid bills or prescriptions unreimbursed or their reimbursement check is late, loss of health insurance, of other benefits or termination from employment. Nurse case managers also serve as a liaison and ensure information is being shared between the insurance carrier, employer, attorneys, medical care providers and the injured worker. This includes addressing questions, providing or obtaining clarification regarding the injured worker's medical care, treatment, return to work capabilities.

Dana Dorsey: 4:47

When needed, a nurse case manager should be considered for claims that include wage loss, claims that have multiple injuries or body parts involved, catastrophic claims such as brain, spinal cord amputation or burn injuries, when an injured worker has a history of several prior claims for an injured worker that is non-compliant with appointments and treatment, or if there has been a surgical recommendation. Nurse case managers can help reduce costs of a claim by reducing lost time, by facilitating early return to work, ensuring treatment stays on track and is medically necessary, per treatment guidelines and discussing and obtaining MMI from the treating provider, offering vendors to the insurance carrier, negotiating per diem rates, single case agreements for inpatient rehab and reducing the likelihood of interning involvement. Thanks for listening today. I hope you have learned something new about the role and benefits of a nurse case manager.

Sara Hance: 5:54

Thank you for tuning in to MEC Connect Expert Insights. At MEC, we focus on what matters most worker recovery and better claims outcomes. Our skilled people, proven processes and innovative technology achieve measurable results and create lasting value. We hope you found Dana's insights on the role of a nurse case manager valuable. Stay tuned for more from MEC Connect and more expert insights. Thank you for listening.