Do’s and Don’t’s regarding nurse case managers that employers and examiners should know

After a while, claims professionals fail to define why they’re using nurse case management and what their expectations should be of those nurses.  I’ve seen folks put a nurse case manager on a case to act as a bulldog in order to get the injured worker’s

status expedited and question the validity of the doctor’s treatment plan.  But one thing is clear, before assigning a nurse case manager to a case, ensure that specific goals and objectives have been communicated to all parties and schedule monthly or bi-weekly  times to review the objectives.  In order to clarify the do’s and don’ts of nurse case manager utilization, below is a list included in a Lexis Nexis article written by Steve Birnbaum, The Case for Clear Guidelines for Nurse Case Managers Copyright 2012


  1. Be inclusive of all parties involved in the medical recovery process, especially the family.
  2. Include goals and time frames when creating the care plan and allow for updates.
  3. Determine if treatment is appropriate.
  4. Determine what is needed for successful return to work, especially from employer’s perspective.
  5. Provide client advocacy and support at all times, and provide input and guidance on treatment services
  6. Use valid disability duration guidelines, and use them as GUIDELINES.
  7. Educate all parties, especially employer, whenever possible on the positive and cost-effective aspects of return to work programs and processes.
  8. Always obtain and maintain appropriate releases of information.
  9. Understand that there are many players in the case management process, but that your main client should always be the injured employee.
  10. At the very start, identify clearly your role as a case manager.


  1. Change employee’s doctor appointments just to fit YOUR schedule.
  2. Perpetuate disability by failing to address doctor recommendations, health concerns, or return-to-work issues in a timely fashion.
  3. Become personally and/or emotionally attached to the clients.
  4. Assume that you have an absolute right to attend all doctors’ appointments despite client wishes against it.
  5. Interfere with due process between employee and employer.
  6. Initiate cost services prior to obtaining carrier authorization.
  7. Provide legal direction to the claims adjuster, or engage in claims investigative or adversarial activities.
  8. Give legal advice at any time.
  9. Schedule independent medical examinations.

Added to these should be considerations of privacy under HIPAA (Health Insurance Portability and Accountability Act, 42 U.S.C.S. § 1320d et seq.) and a transparency of the relationship between the insurance company and the nurse case practitioner.”

Feel free to call us with questions or referrals at (949) 830-2027 or write us at or leave a comment!

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