The Case Manager
Case managers who learn to work effectively with the claims adjusters on their cases often achieve better outcomes for everyone involved. The claims adjuster is an important member of the workers’ compensation team and should be viewed as a partner in the management of the claim—not simply as the person who approves or denies services.
The claims adjuster is responsible for managing the financial and administrative aspects of the workers’ compensation claim. Depending on the state and the specific workers’ compensation system, the adjuster may be responsible for authorizing medical treatment, diagnostic testing, medications, rehabilitation services, and other services related to the injured worker’s care. The adjuster must also ensure that the claim is handled according to the workers’ compensation laws, regulations, and requirements of the state where the injury occurred.
This is an important responsibility. Every worker’s compensation claim has its own circumstances, and requirements can vary from state to state. The claims adjuster must balance the needs of the injured worker with the applicable workers’ compensation regulations, the employer’s interests, and the financial responsibilities associated with the claim.
The nurse case manager and claims adjuster therefore bring different areas of expertise to the same case.
The nurse case manager brings clinical knowledge, healthcare expertise, communication skills, and an understanding of the injured worker’s medical needs and goals. The claims adjuster brings knowledge of the claim, benefits, regulations, authorization processes, and financial responsibilities.
When these professionals communicate effectively, they can develop a coordinated approach to the claim. When communication breaks down, delays, misunderstandings, and frustration can occur.
When an issue arises on a case, the claims adjuster needs to be part of the conversation. A nurse case manager should not assume that an issue can be resolved without involving the adjuster. Early communication allows the team to identify the problem, discuss possible solutions, and determine what needs to happen next.
A good professional relationship does not mean that the nurse case manager and claims adjuster will always agree. In fact, healthy professional relationships allow for differences of opinion. What matters is that both professionals understand their respective roles, communicate openly, respect each other’s expertise, and keep the goal of achieving the best possible outcome for the injured worker at the center of their work.
Here are eight tips both professionals can use to build a strong professional relationship
When a nurse case manager receives a new workers’ compensation case, establishing a positive working relationship with the claims adjuster should be one of the first priorities. The following eight tips can help build that relationship and create a stronger foundation for managing the claim.
1. Introduce yourself and establish communication early.
2. Understand the adjuster’s role and responsibilities.
3. Share important clinical information promptly.
4. Keep the adjuster informed—especially when the plan changes. Like you, the adjuster need up to date information as they have reports to do as part of their role.
5. Bring problems to the adjuster early rather than waiting for them to escalate.
6. Respect the adjuster’s knowledge of the claim and workers’ compensation requirements.
7. Look for solutions together rather than working in silos.
8. Keep the injured worker at the center of the conversation.
The goal is not for the nurse case manager and claims adjuster to do the same job. Their roles are different, but their work is interconnected. When they understand and respect those differences, communicate consistently, and work toward a common goal, they become a stronger team—and the injured worker benefits.
How do you view your relationships with the claims adjusters you have worked with. Feel free to email me at anne@nursesadvocates.com. Would love to know your tips!
Have a good week!
