Nurse Case Manager Chronicles

Learning from the Best: Nurse Case Managers Educate Claims Professionals on Injury

A workers’ compensation claims professional can learn a thing or two about injury from the nurses who manage their claims.
By: | September 28, 2018 • 4 min read

When it comes to complex workers’ compensation claims, have you ever wondered why an injured worker needs a specific type of treatment?

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Employers aren’t always privy to the ins and outs of medical terminology or requirements for healing, but there is someone on the claim who knows it all: the nurse case manager.

“Case managers are the workforces out on the street talking to physicians, insurers, employers and providers,” said Hayley Tidwell, senior clinical care specialist at One Call. “The adjusters are taking care of the claims, but they don’t always have the understanding, background or knowledge on the medical side.”

That’s why One Call began offering continuing education courses for claims professionals on complex and catastrophic claims. All lessons come from their nurses.

“Nurses see cases like this every day. They have the experience to impart wisdom to others in the claims process,” explained Tidwell. “Our classes are a vital problem solving tool for providers, especially when dealing with catastrophic cases, which require a fair amount of medical knowledge.”

The Path to Education

Tidwell, one of the speakers for One Call’s education series, began her career as a nurse in inpatient rehab.

understanding the claims process

Hayley Tidwell, senior clinical care specialist, One Call

It was there where she first encountered injuries similar to those found in workers’ compensation: traumatic brain injuries, spinal cord injuries, hip fractures and shoulder tears.

Tidwell entered into case management, then later joined One Call, where she educates others in the claims process using her own experience in handling injured workers’ claims. She teaches “Clinical Management of the Catastrophic Claim,” where she educates claims professionals about how to handle complex cases.

She uses her own cases to demonstrate what a claims professional should do in similar situations. For example, one case involved an injured worker who was paralyzed after a spinal cord injury. Tidwell said in catastrophic cases like this one, case managers must be aware of different resources for the patient.

“A patient with these types of injuries often requires coordination of an inpatient rehab upon discharge from acute care,” she said. “This particular patient needed physical, occupational and group therapies along with a support network, both personally and medically.”

Claims professionals need to be aware of the funding available for these treatments, because “each claim must have a certain amount of money reserved to pay for the cost,” Tidwell added.

“The amounts vary based on the severity of the injury and the length of disability. The claim and nurse case manager’s understanding of the medical diagnosis, anticipated length of recovery, and possible complications help professionals better predict claims outcomes.”

Teaching a Variety of Claims Courses

Providing claims managers with the tools they need to handle complex cases is just one example of One Call’s commitment to education. One Call also provides courses on common workers’ comp cases, giving claims professionals an opportunity to learn about the tools they didn’t know they needed before a catastrophic event even occurs.

Hot topics include:

  • Medical Marijuana — The speaker reviews how changing legislation in different parts of the country can affect a claim. This not only keeps nurse case managers on top of legislation but also makes sure providers and adjusters know their state’s laws.
  • Elderly in the Workplace — People are staying in the workforce longer, Tidwell explained. With a range in age comes different ways to approach safety. This course looks at how to implement best safety practices at work to prevent injury for those who are more at risk.
  • Catastrophic Claims — Tidwell teaches this course, looking at the more common catastrophic claims that populate workers’ comp. She reviews the medical supplies necessary for recovery and what home supplies a worker might need.
  • Mild Brain Injuries — Concussions are a hot topic, especially with the development and understanding of chronic traumatic encephalopathy, or CTE. Employers who know the signs and symptoms of a concussion can get an employee the help they need quickly.

 Everyone Benefits from Knowledge

Tidwell gets positive feedback for these courses.

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She has also heard from claims professionals who said they didn’t understand why certain treatments were being requested for a claim, but after taking a course, they had a better understanding of workers’ needs.

“These courses provide a 360-degree view on cases that an adjuster might not have had the opportunity to see on their own,” said Tidwell.

“It’s an opportunity to learn about the tools they didn’t know they needed and that’s a win-win for the entire workers’ compensation industry.” &

For those interested in learning more about continuing education courses at One Call, visit here for details.

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

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The R&I Editorial Team can be reached at [email protected]