Nurse Case Manager Chronicles

The Case Manager’s Many Hats

Nurse case managers act as a resource of knowledge, assistance and support for injured workers and everyone involved in their care.
By: | March 26, 2018 • 4 min read

Do you know what your nurse case manager does? Sure, on the surface it’s easy to know the job description — a registered nurse who coordinates all aspects of care for injured workers — but what exactly is a nurse case manager doing each day to help injured workers, save insurers money and keep workers’ compensation claims out of court?

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The answer: They’re wearing many hats. Mediator, moderator, educator, negotiator and expert.

“Nothing is the same from day to day,” said Chikita Mann, a registered nurse and the Georgia branch supervisor for Genex Services, which specializes in medical management. “The most challenging part is working with a number of different personalities.”

A case manager spends their day speaking with doctors, employers, workers, adjusters, insurers and attorneys. That nurse is the go-to person for knowledge and the go-between for each step of the workers’ comp claim.

Knowing People

“I can be very blunt and straightforward sometimes,” Mann said. “I have learned to adapt my own behavior to each person I interact with. No matter the personality, everyone wants to know they are being heard and they have something to contribute to a situation.”

When a worker gets injured, different agendas can cause stress and strife.

Chikita Mann, RN, Georgia branch supervisor, Genex Services

An employer aims to get their worker back on their feet while juggling the workers’ comp claim and their other employees. The injured worker faces confusion about their medical needs while trying to heal from their injury and provide for their family. The carrier reviews the incident, deciding if it’s a compensable injury or not.

The nurse case manager’s job is to keep everyone updated and on task. The nurse educates injured workers on proper care, mediates between the employer and their worker, moderates the physician’s care plan, and negotiates with the employer and insurer to get the best care outcome while saving costs.

“The one thing I hear most is ‘I did not understand how serious this was until I had a conversation with the case manager,’” said Mann. “It’s not just about getting workers back to work; it’s about getting them to the best of their health so they can have a full life.”

An injured worker once called Mann with a complaint about his nurse case manager. He didn’t understand why he needed someone from the medical field who wasn’t his physician on his workers’ comp case.

Mann responded, saying she heard his concern and would like to address it head on. She put on her educator hat, prepared to help the worker understand the nurse’s role, but before they could sit down to talk, the worker called back.

“He said he jumped the gun. He was unaware of what exactly the nurse could do for him, which ended up being beyond his expectations,” said Mann. The worker had a series of comorbidities that pre-dated his injury, and the nurse case manager saw to it that those illnesses were addressed alongside his injury.

But it isn’t always that easy; while some underestimate the nurse case manager’s role, others expect more. If Mann sees tempers starting to rise, her first instinct is to review the case file and ask what is expected of the nurse.

“Sometimes, there is an expectation that the case manager can acquire information about non-work-related medical issues,” Mann said. “However, we are unable to secure this information without a signed medical release from the injured worker.”

“No matter the personality, everyone wants to know they are being heard and they have something to contribute to a situation.” — Chikita Mann, RN, Georgia branch supervisor, Genex Services

Mann explained that a hospital has no legal obligation to “hand over” a worker’s medical records, and the NCM is not able to demand the records be released. Both the hospital and a case manager need to abide by HIPAA.

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“Some states have specific laws on what a case manager can and cannot do,” said Mann. “For instance, in Georgia the injured worker and their attorney have to be copied on all correspondence, like reports or letters. It’s not an option — it is mandatory.”

Some employers, according to Mann, may feel that if something is related to their worker’s comp claim, the employer should be copied on correspondence as well, but that’s not always the case.

Keeping It All on Track

Maintaining knowledge that is both broad-based and highly specific, and carefully balancing the interests of all parties is all business as usual for highly focused NCMs.

“Workers’ comp case managing is challenging, because it requires knowledge from other case managing areas. We have to know workers’ comp jurisdiction and guidelines. We have to know about any comorbidities [in the patient],” said Mann.

“Field case managers need to understand a hospital’s discharge process. Sometimes they need to know how to utilize social work skills, serving as liaisons between different institutions and case parties to assist patients and collaborate with other health professionals.

“It’s structured flexibility,” Mann continued, using a term she coined. “There is a set way of doing case management, however a nurse needs flexibility to adapt to the scenario at hand.” &

Autumn Heisler is the digital producer and a staff writer at Risk & Insurance®. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

High Net Worth

High Net Worth Clients Live in CAT Zones. Here’s What Their Resiliency Plan Should Include

Having a resiliency plan and practicing it can make all the difference in a disaster.
By: | September 14, 2018 • 7 min read

Packed with state-of-the-art electronics, priceless collections and high-end furnishings, and situated in scenic, often remote locations, the dwellings of high net worth individuals and families pose particular challenges when it comes to disaster resiliency. But help is on the way.

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Armed with loss data, innovative new programs, technological advances, and a growing army of niche service-providers aimed at addressing an astonishingly diverse set of risks, insurers are increasingly determined to not just insure against their high net worth clients’ losses, but to prevent them.

Insurers have long been proactive in risk mitigation, but increasingly, after the recent surge in wildfire and storm losses, insureds are now, too.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy,” said Laura Sherman, founding partner at Baldwin Krystyn Sherman Partners.

And especially in the high net worth space, preventing that loss is vastly preferable to a payout, for insurers and insureds alike.

“If insurers can preserve even one house that’s 10 or 20 or 40 million dollars … whatever they have spent in a year is money well spent. Plus they’ve saved this important asset for the client,” said Bruce Gendelman, chairman and founder Bruce Gendelman Insurance Services.

High Net Worth Vulnerabilities

Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

As the number and size of luxury homes built in vulnerable areas has increased, so has the frequency and magnitude of extreme weather events, including hurricanes, harsh cold and winter storms, and wildfires.

“There is a growing desire to inhabit this riskier terrain,” said Jason Metzger, SVP Risk Management, PURE group of insurance companies. “In the western states alone, a little over a million homes are highly vulnerable to wildfires because of their proximity to forests that are fuller of fuel than they have been in years past.”

Such homes are often filled with expensive artwork and collections, from fine wine to rare books to couture to automobiles, each presenting unique challenges. The homes themselves present other vulnerabilities.

“Larger, more sophisticated homes are bristling with more technology than ever,” said Stephen Poux, SVP and head of Risk Management Services and Loss Prevention for AIG’s Private Client Group.

“A lightning strike can trash every electronic in the home.”

Niche Service Providers

A variety of niche service providers are stepping forward to help.

Secure facilities provide hurricane-proof, wildfire-proof off-site storage for artwork, antiques, and all manner of collectibles for seasonal or rotating storage, as well as ahead of impending disasters.

Other companies help manage such collections — a substantial challenge anytime, but especially during a crisis.

“Knowing where it is, is a huge part of mitigating the risk,” said Eric Kahan, founder of Collector Systems, a cloud-based collection management company that allows collectors to monitor their collections during loans to museums, transit between homes, or evacuation to secure storage.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy.” — Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

Insurers also employ specialists in-house. AIG employs four art curators who advise clients on how to protect and preserve their art collections.

Perhaps the best known and most striking example of this kind of direct insurer involvement are the fire teams insurers retain or employ to monitor fires and even spray retardant or water on threatened properties.

High-Level Service for High Net Worth

All high net worth carriers have programs that leverage expertise, loss data, and relationships with vendors to help clients avoid and recover from losses, employing the highest levels of customer service to accomplish this as unobtrusively as possible.

“What allows you to do your job best is when you develop that relationship with a client, where it’s the same people that are interacting with them on every front for their risk management,” said Steve Bitterman, chief risk services officer for Vault Insurance.

Site visits are an essential first step, allowing insurers to assess risks, make recommendations to reduce them, and establish plans in the event of a disaster.

“When you’re in a catastrophic situation, it’s high stress, time is of the essence, and people forget things,” said Sherman. “Having a written plan in place is paramount to success.”

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Another important component is knowing who will execute that plan in homes that are often unoccupied.

Domestic staff may lack the knowledge or authority to protect the homeowner’s assets, and during a disaster may be distracted dealing with threats to their own homes and families. Adequate planning includes ensuring that whoever is responsible has the training and authority to execute the plan.

Evaluating New Technology

Insurers use technologies like GPS and satellite imagery to determine which homes are directly threatened by storms or wildfires. They also assess and vet technologies that can be implemented by homeowners, from impact glass to alarm and monitoring systems, to more obscure but potentially more important options.

AIG’s Poux recommends two types of vents that mitigate important, and unexpected risks.

“There’s a fantastic technology called Smart Vent, which allows water to flow in and out of the foundation,” Poux said. “… The weight of water outside a foundation can push a foundation wall in. If you equalize that water inside and out at the same level, you negate that.”

Another wildfire risk — embers getting sucked into the attic — is, according to Poux, “typically the greatest cause of the destruction of homes.” But, he said, “Special ember-resisting venting, like Brandguard Vents, can remove that exposure altogether.”

Building Smart

Many disaster resiliency technologies can be applied at any time, but often the cost is fractional if implemented during initial construction. AIG’s Smart Build is a free program for new or remodeled homes that evolved out of AIG’s construction insurance programs.

Previously available only to homes valued at $5 million and up, Smart Build recently expanded to include homes of $1 million and up. Roughly 100 homes are enrolled, with an average value of $13 million.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work.” — Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“We know what goes wrong in high net worth homes,” said Poux, citing AIG’s decades of loss data.

“We’re incenting our client and by proxy their builder, their architects and their broker, to give us a seat at the design table. … That enables us to help tweak the architectural plans in ways that are very easy to do with a pencil, as opposed to after a home is built.”

Poux cites a remote ranch property in Texas.

Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“The client was rebuilding a home but also installing new roads and grading and driveways. … The property was very far from the fire department and there wasn’t any available water on the property.”

Poux’s team was able to recommend underground water storage tanks, something that would have been prohibitively expensive after construction.

“But if the ground is open and you’ve got heavy equipment, it’s a relatively minor additional expense.”

Homes that graduate from the Smart Build program may be eligible for preferred pricing due to their added resilience, Poux said.

Recovery from Loss

A major component of disaster resiliency is still recovery from loss, and preparation is key to the prompt service expected by homeowners paying six- or seven-figure premiums.

Before Irma, PURE sent contact information for pre-assigned claim adjusters to insureds in the storm’s direct path.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work,” said Curt Goetsch, head of underwriting for Ironshore’s Private Client Group.

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“If you’ve got custom construction or imported materials in your house, you’re not going to go down the street and just find somebody that can do that kind of work, or has those materials in stock.”

In the wake of disaster, even basic services can be scarce.

“Our claims and risk management departments have to work together in advance of the storm,” said Bitterman, “to have contractors and restoration companies and tarp and board services that are going to respond to our company’s clients, that will commit resources to us.”

And while local agents’ connections can be invaluable, Goetsch sees insurers taking more of that responsibility from the agent, to at least get the claim started.

“When there is a disaster, the agency’s staff may have to deal with personal losses,” Goetsch said. &

Jon McGoran is a novelist and magazine editor based outside of Philadelphia. He can be reached at [email protected]