Nurse Case Managers: Their Role in Your Workers’ Compensation Claim

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If you have been injured on the job and filed a workers’ compensation claim you may be assigned a nurse case manager. Your employer’s workers’ compensation insurance company will typically hire a nurse case manager to help coordinate your care as the injured employee. If you have been injured on the job you should know the role a nurse case manager will have in the claims process.

Who Does the Nurse Case Manager Work for?

The job of a nurse case manager is to work directly for and advocate for you, the injured worker. However, because the workers’ compensation insurance company hired the nurse, there is often the presumption that the nurse is acting on behalf of the insurance company. This is not always the case.

A nurse case manager is a RN who is registered with the North Carolina Industrial Commission to help coordinate the care of injured workers. The nurse case manager often has the task of helping to coordinate your treatment with multiple physicians while keeping both the attorney and the insurance company aware of your ongoing medical treatment.

What Rules Must the Nurse Case Manager Follow?

The purpose of having a nurse case manager is to assist you to recover from your work injury as nearly as possible to your pre-injury physical function. The nurse case manager must always abide by the North Carolina Rehabilitation Professional Rules and as such must advise the you of their role and the rules associated with their involvement in your workers’ compensation claim.

A nurse case manager can be very helpful in a complicated medical case provided that both you, the injured worker and the nurse case manager understand and agree to the rehabilitation rules.

The nurse case manager is a neutral party in a workers’ compensation claim whose purpose is to help ensure that you are obtaining the necessary treatment as recommended by your physician.

Your Rights When Dealing with the Nurse Case Manager.

When dealing with a nurse case manager, the two most important rules are that:

1. You, the injured worker, are entitled to a private examination with your physician.

The first rule, that you are entitled to a private examination, should always be followed, even if you have a good rapport with the nurse case manager.

Ultimately your health care is personal and as a patient you have the right to a private exam without any inference from the insurance carrier or a person acting on behalf of the insurance carrier.

There may be times when you need to speak with your physician about an issue that may not be relevant to your work injury or need reassurance from your physician regarding your care that otherwise you would not receive in the presence of the nurse case manager. It is for reasons such as these that it is important not to get into the habit of letting a nurse case manager be present during the physician’s exam.

2. The nurse case manager cannot engage in communications with the physician outside of your presence unless you agree, and/or the physician insists upon it or in emergency situations.

The second rule is one that can be problematic if it is not followed, especially if the nurse case manager is not truly working as a neutral advocate.

As mentioned earlier the nurse case managers goal is to assist you to be restored as nearly as possible to your pre-injury physical function. However sometimes the goal can be misguided and becomes about satisfying the insurance company’s need to save money.

Nurse case managers do this is by making suggestions to the physician to change the treatment plan for your work injury. By allowing the nurse to have discussions with the physician outside of your presence the nurse can persuade the physician to change the treatment plan without your knowing. This could ultimately be detrimental to your rehabilitation and your involvement in your own care.

Finally, before a nurse case manager becomes involved in an injured worker’s care, they must file a 25N Notice to the Commission of Assignment of Rehabilitation Professional and offer the injured worker a copy of the Rules for Utilization for Rehabilitation Professionals.

For a summary of those rules, click here: http://www.ic.nc.gov/MRPRehabSummary011217.pdf

If you have been injured at work and have questions regarding your workers’ compensation claim and the role of a nurse case manager please call Mullen Law, P.A., an experienced North Carolina Worker’s Compensation law firm for a free consultation.

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A personal injury, medical malpractice and workers' compensation law practice committed to representing individuals who have been injured or lost a loved one as a result of negligence or who were injured or lost a loved one while working on the job. Mullen Law, P.A. takes a "holistic" approach to your case. We identify all of the your legal and individual or family needs, fight for your rights and ensure that you receive the highest quality legal and individualized attention in order to obtain the highest monetary outcome considering all aspects of your case.