Nurse Case Managers in California Workers’ Comp

We’ve now mentioned the many different stakeholders that can enter a workers’ comp claim. The stakeholders in any and every work comp claim are the injured worker, the PTP (Primary Treating Physician), and the insurance adjuster. In California, if a claim gets tricky, an attorney and a QME can join the claim.

Still more stakeholders can join the claim in order to help things along. The nurse case manager is one such stakeholder.

What is a Nurse Case Manager?

A nurse case manager, simply put, is the individual (usually a registered nurse) who is responsible for managing a workers’ compensation claim. For our purposes, the words case and claim are the same thing.

There are so many factors in a single workers’ compensation claim that details both big and small can be overlooked. It is the case worker’s job to make sure that the claim is going smoothly.

For the injured worker, the nurse case manager will make sure that their appointments are scheduled and their injuries are prioritized and documented. In some cases, nurse case managers arrange rides for injured workers who have trouble getting to their appointments. They are also responsible for making sure that the injured worker is getting the correct care and treatment for the injury.

The nurse case manager will then communicate the results of visits and examinations from the PTP to the insurance adjuster. They will also relay any information that the insurance carrier has to send back to the PTP or the injured worker. They may be in attendance for the injured worker’s appointments, attend court hearings when attorneys are involved, and more.

Since both PTPs and insurance carriers are working on multiple claims at once, communication between the two can go very slow sometimes, at the expense of the injured worker. Having a person that works on one claim specifically (the nurse case manager’s job) can be a tremendous help.

Who Does the Nurse Case Manager Work for, and Why are They On My Claim?

The nurse case manager is an impartial third party who is hired by the employer’s insurance company. A nurse case manager will be called in for a claim if the insurer feels that it’s necessary to hire one. This can be because a claim is dragging on and the insurer wants more scrutiny on the doctor or injured workers’ visits.

In a perfect world, workers’ comp would mean an insurance company handing over the exact dollar amount owed for a specific injury. Because of the countless different factors that can complicate a work comp claim, nothing is so cut and dry. This makes hiring a nurse case manager necessary in some cases.

Wait a Second…

You might be wondering how a nurse case manager can be impartial when they are working directly for a stakeholder in the claim. This is a very valid question.

Essentially, the information that the nurse case manager conveys between parties is accurate and impartial, but it is what the stakeholders do with the information given to them that can affect how the claim plays out. Attorneys may advise an injured worker to keep their communication about their claim to a bare minimum, in case something that they told the nurse case manager could be used against them in court.

Conclusion

Different medical professionals can enter a claim for all different reasons. Though they might seem similar, they each serve a different purpose. A QME differs from a nurse case manager in that the QME acts as a secondary physician for the injured worker, while the nurse case manager takes care of all of the arrangements and paperwork of the claim without ever doing any examinations themselves.

Opinions may differ on which side a nurse case manager is really on, but an understanding of what they do can prove that a nurse case manager can be very effective at moving a claim along. If there is a nurse case manager who is brought onboard for your claim, refer back to this article to remember some best practices when working with them.

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