Transition into insurance case management from the floor

nurseprnRN, BSN, RN · May 1, 2015

They know you haven't done it before. They're hiring you for your nursing knowledge and skills, including assessment, patient teaching, communication of medical info to nonmedical folks, ability to work c physicians and therapists, documentation, and the like. They'll teach you the rest of it. :)

WC Case manager · May 11, 2015

You will usually be responsible for working with a lot of adjusters. You need to think outside the box. Go further than what you just see but look into the future for possibilities of what could happen or what could be needed. Always anticipate.

nurseprnRN, BSN, RN · May 18, 2015

I posted this once upon a time on how I used to look at it.

This is absolutely a nursing job, even though, like many nursing and other professional jobs, the documentation and notification doesn't feel like it. You will start having a greater appreciation of this as you do it for awhile.

The definition of case management includes influencing the course of medical care. You are NOT a passive observer/recorder. Even though you work for the carrier and are charged with watching for unnecessary costs, you are a nurse and patient advocate first. That's why they hired you. For an example:

You get a referral for an IW with a knee injury. He has been seen by the occ med clinic and referred to an orthosurg for possible repair. To do your initial assessment, you go to his house. You take a full history, including a vocational history. Why? Because your first phone call back at the office will be to the employer, asking about modified duty later when he gets clearance for it. If they don't have an established modified duty program, you're going to help them see the wisdom of it and explain what he will probably be able and not able to do over the course of his recovery.

Meanwhile, back at the house doing your initial eval, you go into patient teaching mode, explaining the entire process and saying that you will meet him at the MD office appt and what will probably happen there. You obtain a signed release for medical records from him. If you are smart, you say that some people might tell him that you work for the insurance company, you don't care about him, you just want to save money. However, you are a nurse first and your duty is to see he gets good care.

Besides, you say, there is nothing inherently wrong about saving money; if we were all independently wealthy neither of us would be here right now, right? Comp is an insurance plan his employer pays for, just the way he pays for car insurance. If you get him better faster, he gets back to work sooner rather than later the employer saves money on premium, AND saves money on training a replacement who doesn't know the job as well as he does. And of course, if he gets better faster, the carrier saves money. And if he gets better faster, he earns more money too, because comp indemnity isn't as much as he was earning, is it? So voila, everybody does better when he gets better and goes back to work except you, because you are on salary. He laughs, and you take your leave.

At the appt, you give the office mgr a copy of the release and attend the exam with the patient's permission to observe. This is critical, so you are glad you put the time into developing rapport and trust with him at your initial eval. You listen to what the physician has to say, take good notes (also noting if the physician does a good exam, asks about what the job entails physically, and takes a good history) and tactfully insert missing data the MD forgets to ask. Or say, "Mr. IW had some concerns about ..." when the doc looks about to leave without asking. Or, perhaps, making a mental note that perhaps a second opinion might be a good idea.

Surgery is recommended and scheduled. You will make the first postop appt AND the first postop PT eval appointment according to the physician's routine before you leave the MD office. This is because you will know that the doc will say that PT can proceed right after the first postop check, because you will ask. You will attend that postop check, but if you wait to call to make the PT appt til then, you won't get your guy seen until a week or two later, and this is an unnecessary delay. If for any reason the postop check indicates a need to postpone, you can always do that. You will also arrange to get the office notes faxed to you stat. Finally, when you and the IW leave the office, you say, "Did you understand what Dr Smith plans about your surgery and postop care?" Dollars to doughnuts the answer will be something like, "Ummm, sorta..." and you will explain the treatment plan all over until you are satisfied that he understands it. If he isn't happy with it, or you aren't, you explain that he can have a second opinion, and you know the best knee guy in town who will get him in within a week or two. And remember, since this is comp, the "in network" thing from his regular health insurance DOES NOT APPLY, so you ca do that.

So the surgery goes down and he goes to a good PT place you recommended, because you know who's good at that. Like surgeons and hospitals, all PT facilities are not created equal. You get a copy of his initial eval and call to see that he's doing OK c it. You see him at the MD office in follow up in a month, and because you have already been working with the employer, you have a job description for a desk job while he recovers. The physician ticks off the boxes for physical aspects, hours, and days on the form you have for him (and you may have created yourself), so the employer knows what's OK.

There's more, but you can see that all along you are using your nursing expertise in assessment, patient teaching, teamwork, planning, and documentation to move this IW along the continuum of care in more ways than just being a passive observer. You are also educating the adjuster, who may know less about knees than you think, especially if you know Dr Smith has lousy outcomes and you'd like to have the IW seen by Dr Excellentkneeguy, who you know is very functionally-oriented and gets people back to full function faster. YOU are the most important variable in thus guy's recovery.

Hope that gives you a teeny taste of field case mgmt in work comp. As you get more expertise, as in any other nursing specialty, you get better at it, with different injuries, diagnostics, specialties, and acuities. And personalities. As in any nursing specialty, there are some nonadherent patients, liars, and scumbags, and you will learn how to work with (or around) them. The vast majority of IWs really did get hurt, really do want to get better, and really do want to RTW, and you will make all the difference to them.