What is the Role of a Workers’ Compensation Nurse Case Manager?

Perhaps the best way to define the role of a workers’ compensation nurse case manager is to look at the broader definition of case management that is promulgated by a professional organization of case managers:

Case management is a collaborative process of assessment, planning and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes[1].

A nurse case manager is a nurse, usually an RN, who takes what might be called an “aerial view” of a workers’ compensation claim. The suggestion that an “aerial view” is taken means that a workers’ compensation claim has both medical and legal aspects, both of which must be considered.

The medical aspect of a nurse case manager’s role is similar to the duties of any nurse. Those include that his or her loyalty must be solely to the injured individual and best efforts must be employed to provide proper, efficient and medically efficacious care. The legal aspect of the role stems from the fact that workers’ compensation claims are governed by a statutory body of law that defines and delimits the rights and remedies of the injured individual. This may, at least in theory, result in a conflict for the nurse case manager. The initial control of the medical care and rehabilitation is part of the “trade-off” for the employee not having to prove fault by the employer in causing a work-related injury as discussed in our prior blog. However, the injured individual can usually challenge the propriety or sufficiency of the rehabilitation plan.

Both the medical and legal aspects must be carefully considered and executed by the nurse case manager. This is because the nurse case manager is normally engaged by the employer, if self-insured, or by the workers’ compensation insurer or by a third-party administrator. A third-party administrator is an entity, usually licensed by a state department of insurance, to which is outsourced the processing of claims and that can be engaged either by a self-insured entity or by an insurer.

Historically, nurse case managers were utilized mainly in catastrophic injury claims. However, as time went by and their utility became clearer, they began to be used in other types of claims, including those involving a lesser degree of trauma. The goal, however, remained the same: to design, implement and monitor a schema of post-acute care. At NeuLife a customized Client Goal Plan is developed for each client, to provide rehabilitation, specialized rehabilitation and other clinically relevant services, with the ultimate goal of achieving the best possible outcome for the individual.

The nurse case manager is, in a sense, an extension of the workers’ compensation adjuster, but performs any or all of the following functions:

• Assesses the medical aspects of the illness, injury or trauma that gave rise to the claim;
• Corresponds with treating physicians and arranges for referrals to specialists as needed;
• Ensures that physicians keep employers, workers’ compensation insurers and third-party administrators apprised of recommendations, including returning to work and any restrictions on employment;
• Provides input to the rehabilitation plan and recommended clinically relevant services, such as the Client Goal Plan that NeuLife develops;
• Evaluates and monitors the individual’s progress in rehabilitation and specialized rehabilitation;
• Recommends the appropriateness and the types of post-acute care to achieve the best possible outcome for the individual by the most cost-efficient means;
• Acts as a liaison between the injured individual, the medical provider, the employer and/or the workers’ compensation benefit provider as to medical and rehabilitation issues. In this regard, the nurse case manager does not tell the treating physician what to do or how to treat the physical condition of the individual. Instead, one of the functions of a nurse case manager is to ensure that the medical provider knows every factor that can impact rehabilitation and the individual’s return-to-work status.

The professionals at NeuLife, including its team of neurologists, RNs and therapists are expert in the provision of innovative, clinically relevant services, including the creation of a customized Client Goal Plan, and delivery of neurobehavioral and neurorehabilitative services. NeuLife’s goal is to provide post-acute rehabilitation to its clients to achieve the best possible outcome for those who have even the most difficult and challenging diagnoses.

NeuLife’s philosophy is that healing, wellness and personal fulfillment are best accomplished in a positive and uplifting therapeutic environment where caring staff encourage, assist and support each client so he or she may achieve specific goals. NeuLife believes personal fulfillment is equally as important as goals to increase function and independence. NeuLife seeks to achieve maximized, sustained outcomes that exceed the expectations of all persons served.

NeuLife, in Mount Dora, Florida, is a fully accessible residential post-acute program providing specialized rehabilitation to individuals diagnosed with traumatic brain injury (TBI), spinal cord injury (SCI), traumatic amputations and other catastrophic injuries.

2725 Robie Avenue

Mount Dora, Florida 32757