The Case Manager’s Many Hats
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?
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.
“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.
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.
“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.” &