A workers' compensation claim is more than a file to be managed. There is a real person navigating an often-complex road to recovery—and every decision along the way can influence the outcome. Yet one of the most valuable resources in that process is sometimes viewed as an added service rather than a strategic advantage: nurse case management.
What if the key to better claims outcomes isn't just managing the claim more effectively, but connecting the right clinical expertise to the process at the right time?
We are all cognizant that workers’ compensation claims involve more than processing medical bills and managing indemnity costs. There are many factors that influence an injured workers’ recovery including timely access to care, appropriate treatment, communication and coordination around multiple stakeholders. Fragmentation in any of these aspects creates unnecessary delays, increases claim complexity and have a negative impact on outcomes. Nurse case management can be the critical component to connect clinical care with effective claims management.
So, what should effective nurse case management bring to the claims process that traditional claims administration alone may not provide? Nurse case management inherently should leverage and utilize the case manager’s clinical expertise at key points throughout the recovery process and, for more complex claims or more complex injured employees, on a longer or more consistent level of intervention. Effective case management serves as a bridge to facilitate communication between injured workers, treating providers, adjusters, employers, and other stakeholders.
Additionally, case managers should be proactively identifying barriers to recovery and addressing them before they become larger obstacles and delay recovery. Education is a necessary component of effective case management. While most parties in the claims process consider the injured worker the key person who requires education, all parties in the process may need education to cover key points such as the pre-authorization process or aspects of the medical or comorbid conditions. In an increasingly complex medical treatment setting, the case manager serves as the connection to apply their medical knowledge to the claims process.
Benefits to strategic utilization of case management include timely medical intervention and coordination which may help reduce unnecessary treatment delays. Having a medical professional proactively managing the medical portion of the claim and identifying medical, psychosocial, and occupational barriers all help prevent avoidable claim complications. This proactive monitoring can identify changes in medical status or recovery that require additional attention.
In short, case management helps translate clinical needs into actionable strategies that support recovery, claim progression and return-to-work goals.
Business value for resources such as case management may be hard for some employers and claims staff to see. Case management supports a more efficient utilization of medical resources through coordinated care, helps reduce avoidable delays, promotes improved communication and collaboration among claims and clinical professionals and supports appropriate return-to-work opportunities while supporting all members of the claims process through medical recovery. The value of case management extends beyond the medical component of the claim, influencing efficiencies, workforce recovery, and overall claim performance.
When clinical care and claims management work together, the result is more than a well-managed claim, it leads to a better recovery experience, a stronger return to work outcome and provides greater value for all stakeholders.
Effective workers’ compensation programs recognize that clinical care and claims management are not only connected, but inherently necessary on the right claims at the right time.
About Our Author: Aimee Boggs has over 30 years of experience in the nursing and workers’ compensation managed care industry. Prior to EK Health, Aimee worked in various case management leadership roles including Manager of Case Management Continuum, Manager of Nursing/Managed Care, and Senior Managed Care Specialist.
Before progressing to these leadership roles, she developed a solid foundation for nursing and clinical case management as a Clinical Nurse and Case Manager. Aimee is a Registered Nurse (RN) and has earned a Master of Science, Health Informatics from the University of South Florida, and a Bachelor of Science, Nursing from the same institution. She also earned an Associate Degree in Nursing from South Georgia College.
As the Vice President of Case Management, her key dutiesinclude oversight of case management handling and operations for multiple EK Health clients and working with new and existing clients for case management processes and implementations. She also has oversight of the EK Health’s case management department that works closely with other EK Health department executives to help ensurethat injured employees receive the highest quality clinical care at the optimal levelfor recovery, safe return to work, and medical cost containment.