Role of the Nurse Case Manager in Workers’ Compensation


As an injured worker going through the workers’ compensation claims process in Virginia you will likely have to attend multiple doctors’ appointments, schedule and attend physical therapy visits and diagnostic imaging appointments, and order and pick up prescription medications and necessary medical equipment such as canes and braces. This is a lot to deal with when you’re trying to recoverĀ from a serious work injury.


Sometimes the workers’ compensation insurance carrier will hire a nurse case manager to help you with these tasks. This article explains the role of the nurse case manager in Virginia workers’ compensation cases and what you can do to protect your legal rights by limiting the nurse case manager’s role. Remember – the nurse case manager assigned to your case works for the employer and its insurance carrier, not you.


If you have additional questions or comments about dealing with a nurse case manager, or are looking for a top-rated workers’ compensation lawyer to help you with your case, contact Corey Pollard today for a free strategy session. We’ve helped hundreds of injured and disabled workers navigate Virginia workers’ compensation and obtain top-dollar workers’ compensation settlements.


What Does a Nurse Case Manager Do in Workers’ Compensation Claims?


Most nurse case managers are registered nurses employed by the workers’ compensation insurance carrier or a vendor used by the insurance carrier. They may attend your medical appointments, but only with your permission, and communicate with you and your treating physician about your treatment and recovery. Your treating physician, however, does not have to discuss your case with the nurse case manager.


In theory a nurse case manager is supposed to:


  • Help you receive the medical care that you need to recover from your work injury
  • Coordinate with you, your authorized treating physician, and the employer and the insurance company on medical issues
  • Help you schedule upcoming medical appointments and arrange transportation if needed
  • Provide information to the insurance company regarding your care
  • Provide authorization to your doctors for recommended treatment


A good nurse case manager serves as an objective third party who can ensure accurate communication between the parties and who can make sure that your medical care is progressing effectively and helping you return to work. If you are not receiving the medical care you need, or if the insurance company is dragging its feet on authorization, a good nurse case manager will step in and raise concerns so that you get the needed treatment.


Sounds great, doesn’t it? Someone to look out for you while you try to get better. In practice, however, some nurse case managers are anything but objective and independent.


In our experience some insurance companies use nurse case managers to try to build evidence against you and to reduce the amount of indemnity and medical benefits they must pay out. For example, the nurse case manager may try to pressure the doctor into opting for conservative treatment instead of an operation that the doctor knows will help you recover better. Or the nurse case manager may pressure your doctor to release you to light duty work or even full duty work before the doctor thinks it’s appropriate. Why? Because the nurse case manager is trying to help the workers’ compensation insurance company save money – and having to pay for surgeries or provide you with temporary total disability benefits while you’re out of work costs money.


Because insurance companies want nurse case managers to keep costs down, there may be conflict between you – the injured worker who wants to try all possible medical treatment if it will help you recover better and faster – and the nurse case manager who wants what is best for the insurance company. If you suspect that the nurse case manager is serving as an advocate for the insurance company and not looking out for your interests, contact a workers’ compensation lawyer right away. By taking quick action your attorney can limit the damage caused by a biased nurse case manager.


Your Rights as an Injured Worker with a Nurse Case Manager in Virginia


If a nurse case manager is assigned to your Virginia workers’ compensation claim, it’s important to remember that he or she is an agent of the insurance company. The nurse case manager is there to monitor your medical treatment and report back to the insurance adjuster or defense attorney. We recommend being polite, but keeping in mind that the nurse case manager is there to help the insurance company limit the amount of money it has to pay to you or on your behalf.


Here are some tips to help you deal with the nurse case manager in your workers’ comp claim:


1. Ask the doctor for a private examination. The nurse case manager may show up to your appointment. But he or she does not have a right to stay in the room while your treating physician examines you. By keeping the nurse case manager outside the room, you can discuss your medical issues and symptoms with your physician privately. You can also discuss any problems that you’re having with the insurance company or the nurse case manager – especially if treatment is not being authorized – with your doctor.


2. Ask the doctor and nurse case manager to be present during their discussions. If you do not allow the nurse case manager to stay in the room during your medical examination (and you shouldn’t), then he or she may ask to speak with the doctor after you’ve left. Don’t let this happen! Make it clear to your doctor and the nurse case manager that you would like to be present during all their discussions. We’ve seen injured workers leave an appointment with light duty work restrictions, in writing, only to find out a few days later that the nurse case manager persuaded the doctor to release them to full duty work after they had left the appointment.


3. Tell your doctor that you would prefer if he or she did not talk to the nurse case manager. Your treating physician may talk to the nurse case manager without your consent. But if you tell your doctor that you would prefer that he or she did not, then your doctor may limit what he or she discusses with the nurse case manager or try to avoid having discussions with the nurse case manager all together.


4. Do not let the nurse case manager change your authorized treating physician without discussing the change with your attorney. If the nurse case manager finds that he or she is unable to persuade your doctor to release you back to work sooner or to opt for conservative treatment over surgery, then the nurse case manager may try to persuade you to switch to a doctor that he or she knows is more likely to be line with the insurance company’s interests. Do not let the nurse case manager pick your doctor. This is a mistake that is difficult to overcome.


5. Always keep your attorney informed. If you have any discussions with your nurse case manager, or if you believe that your doctor is changing your treatment protocol or work restrictions based on discussions with the nurse case manager, tell your attorney immediately. Your attorney can take action to limit the nurse case manager’s role, including asking for the Commission to intervene to stop medical management by the insurance company or requesting a change in treating physician to a more independent doctor.


How We Can Help You Handle the Nurse Case Manager in Your Virginia Workers’ Compensation Case


As your attorney, we will be proactive in keeping the nurse case manager under control. As soon as a nurse case manager is assigned to your case, we will contact him or her and tell them what they can and cannot do. It’s important to set rules from the beginning, before the nurse case manager is able to gain influence over your doctor.


We believe in limiting the nurse case manager’s role to scheduling your appointments and helping us get authorization for medical treatment recommended by your authorized treating physician. We will not allow the nurse case manager to bully you or to get information from you that may be harmful to your case. And we will do everything we can to limit communication between the nurse case manager and your doctor when you are not present.


If you have been hurt and are dealing with a rude or difficult nurse case manager, call or email us today for a free strategy session. Corey Pollard is here to protect your legal rights. We represent injured workers across Virginia, including Richmond, Newport News, Hampton, Norfolk, Virginia Beach, Fredericksburg, Fairfax, and Prince William County. And we can help you navigate any workers’ compensation medical issues that may come up.