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
- Be inclusive of all parties involved in the medical recovery process, especially the family.
- Include goals and time frames when creating the care plan and allow for updates.
- Determine if treatment is appropriate.
- Determine what is needed for successful return to work, especially from employer’s perspective.
- Provide client advocacy and support at all times, and provide input and guidance on treatment services
- Use valid disability duration guidelines, and use them as GUIDELINES.
- Educate all parties, especially employer, whenever possible on the positive and cost-effective aspects of return to work programs and processes.
- Always obtain and maintain appropriate releases of information.
- Understand that there are many players in the case management process, but that your main client should always be the injured employee.
- At the very start, identify clearly your role as a case manager.
- Change employee’s doctor appointments just to fit YOUR schedule.
- Perpetuate disability by failing to address doctor recommendations, health concerns, or return-to-work issues in a timely fashion.
- Become personally and/or emotionally attached to the clients.
- Assume that you have an absolute right to attend all doctors’ appointments despite client wishes against it.
- Interfere with due process between employee and employer.
- Initiate cost services prior to obtaining carrier authorization.
- Provide legal direction to the claims adjuster, or engage in claims investigative or adversarial activities.
- Give legal advice at any time.
- 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.”
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