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Telephonic Case Management

Telephonic case management is the systematic evaluation of medical services, procedures, facilities for medical necessity, appropriateness and efficiency. This promotes optimal patient outcomes, reduces period of disability and assures high quality of care while controlling costs. This is an injury management program that provides early assessment and medical management for Workers' Compensation claims. The goal of the program is to direct the injured employee to appropriate care setting at the onset of the claim to reduce or eliminate unnecessary or inappropriate medical care.

A nurse facilitates the medical activity on a file with the ability to individualize the plan of care and coordinate early return-to-work strategy with the employer and medical provider.

The functions include:

  • Coordination and referral to network medical providers
  • Coordination of the treatment plan with the provider
  • Refer issues to the Utilization Review Department per agreed protocol
  • Working with the provider to establish functional abilities and conditional release to return to work
  • Discussion with the injured worker to clarify the worker's understanding of the diagnosis and treatment plan
  • Monitor the treatment compliance of the injured employee
  • Identify and assist in the resolution of problems with compliance to the treatment plan
  • Provide regular reports to the claims handler to assist in the management of the claim
  • Recommend on-site case management and vocational services when needed
  • Work with the employer to identify a medically appropriate job