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 a staff writer at Risk & Insurance. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

2018 Most Dangerous Emerging Risks

Emerging Multipliers

It’s not that these risks are new; it’s that they’re coming at you at a volume and rate you never imagined before.
By: | April 9, 2018 • 3 min read

Underwriters have plenty to worry about, but there is one word that perhaps rattles them more than any other word. That word is aggregation.

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Aggregation, in the transferred or covered risk usage, represents the multiplying potential of a risk. For examples, we can look back to the asbestos claims that did so much damage to Lloyds’ of London names and syndicates in the mid-1990s.

More recently, underwriters expressed fears about the aggregation of risk from lawsuits by football players at various levels of the sport. Players, from Pee Wee on up to the NFL, claim to have suffered irreversible brain damage from hits to the head.

That risk scenario has yet to fully play out — it will be decades in doing so — but it is already producing claims in the billions.

This year’s edition of our national-award winning coverage of the Most Dangerous Emerging Risks focuses on risks that have always existed. The emergent — and more dangerous — piece to the puzzle is that these risks are now super-charged with risk multipliers.

Take reputational risk, for example. Businesses and individuals that were sharply managed have always protected their reputations fiercely. In days past, a lapse in ethics or morals could be extremely damaging to one’s reputation, but it might take days, weeks, even years of work by newspaper reporters, idle gossips or political enemies to dig it out and make it public.

Brand new technologies, brand new commercial covers. It all works well; until it doesn’t.

These days, the speed at which Internet connectedness and social media can spread information makes reputational risk an existential threat. Information that can stop a glittering career dead in its tracks can be shared by millions with a casual, thoughtless tap or swipe on their smartphones.

Aggregation of uninsured risk is another area of focus of our Most Dangerous Emerging Risks (MDER) coverage.

The beauty of the insurance model is that the business expands to cover personal and commercial risks as the world expands. The more cars on the planet, the more car insurance to sell.

The more people, the more life insurance. Brand new technologies, brand new commercial covers. It all works well; until it doesn’t.

As Risk & Insurance® associate editor Michelle Kerr and her sources point out, growing populations and rising property values, combined with an increase in high-severity catastrophes, threaten to push the insurance coverage gap to critical levels.

This aggregation of uninsured value got a recent proof in CAT-filled 2017. The global tally for natural disaster losses in 2017 was $330 billion; 60 percent of it was uninsured.

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This uninsured gap threatens to place unsustainable pressure on public resources and hamstring society’s ability to respond to natural disasters, which show no sign of slowing down or tempering.

A related threat, the combination of a failing infrastructure and increasing storm severity, marks our third MDER. This MDER looks at the largely uninsurable risk of business interruption that results not from damage to your property or your suppliers’ property, but to publicly maintained infrastructure that provides ingress and egress to your property. It’s a danger coming into shape more and more frequently.

As always, our goal in writing about these threats is not to engage in fear mongering. It’s to initiate and expand a dialogue that can hopefully result in better planning and mitigation, saving the lives and limbs of businesses here and around the world.

2018 Most Dangerous Emerging Risks

Critical Coverage Gap

Growing populations and rising property values, combined with an increase in high-severity catastrophes, are pushing the insurance protection gap to a critical level.

Climate Change as a Business Interruption Multiplier

Crumbling roads and bridges isolate companies and trigger business interruption losses.

 

Reputation’s Existential Threat

Social media — the very tool used to connect people in an instant — can threaten a business’s reputation just as quickly.

 

AI as a Risk Multiplier

AI has potential, but it comes with risks. Mitigating these risks helps insurers and insureds alike, enabling advances in almost every field.

 

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]