Nurse Case Manager Guidelines

GUIDANCE REGARDING THE ROLE OF THE NURSE CASE MANAGER IN THE INDIANA WORKER’S COMPENSATION ARENA

Ideally, a nurse case manager (NCM) is a liaison among the medical provider, the employer and the injured worker.  While not an indispensable player in the Indiana worker’s compensation process or specifically governed by the Worker’s Compensation Act, the nurse case manager can play an integral role in the coordination of medical treatment and the stay-at-work/return-to-work process.

A NCM may provide information that speeds up the process of returning the injured worker to work as well as their recovery from the workplace injury. An example would be providing details about the workstation that may not otherwise be available to the medical provider when evaluating work restrictions or a timely return to work.

Likewise, the NCM may know specifics about the worker’s treatment plan that would be useful to the employer in finding suitable work within the employee’s medical restrictions. The NCM can also explain the treatment plan to the worker if there are questions about the medical terminology used.

The NCM can ensure the claim’s adjuster is aware of the injured worker’s medical needs, so they can assist in expediting access to prescriptions, DME, medical tests, therapies, etc., as ordered by the treating physician.

The NCM’s role in worker’s compensation in the State of Indiana includes, among other things, providing information and communication among the parties and medical providers, scheduling appointments, helping to facilitate care recommended by the treating physician and reporting back to the employer and/or carrier.  Any written notes or report prepared by a NCM and provided to the employer, adjuster or medical provider should also be made available to the injured worker upon request or shall be provided upon Board order.  This does not include billing reports.

The NCM’s communication with the injured worker should be limited to details of the workplace, the relevant injury, medical treatment and pertinent history.

It is not the role of the NCM to determine compensability, make decisions regarding the administration of workers compensation benefits, deliver or direct treatment, or provide medical opinions to either the injured worker or the medical provider regarding the worker’s appropriate course of medical care. However, this is not to say the NCM is precluded from making inquiries as to the treatment/medication options available to the worker from the medical provider.

The NCM must inform the employee that they may require that the NCM not be present during a medical examination.  If the NCM meets with the physician before or at the conclusion of a medical appointment, the injured worker must be invited to participate as well.

All NCMs working in the field of worker’s compensation in Indiana must hold a professional degree as well as credentials through an approved certification organization, or be actively working toward credentials. Examples are a Certified Case Manager (CCM) certification through the Case Management Certification Commission (CMCC). URAC recognizes 9 different case management certifications.  The Board will also accept these.

Any NCM who is not yet certified must work under the supervision of one who is.  All NCMs must follow the Standards of Practice for Case Managers put forth by the Case Management Society of America (CMSA) as well as the CMCC’s Code of Conduct.

It must always be remembered that Indiana law places the responsibility for directing the medical care of a person injured in the course and scope of their employment solely on the authorized treating physician and the Board.  IC 22-3-3-4.  For further guidance, see IC 22-3-3-6.