What Is a Nurse Case Manager in Carolina Workers’ Comp Cases?

If you have been injured at work, your employer’s insurance company may inform you that they have hired a nurse case manager for your case to help coordinate your medical care. Sounds good, right? Well, depending on whether or not the nurse case manager abides by the rules, having one can actually harm your workers’ comp case.

Nurse case managers facilitate communication with doctors and keep track of your appointments. They are coordinators who do not and must not provide direct medical care. The insurance company hired your nurse case manager to essentially be its eyes and ears at your doctor’s appointments. Anything you tell your nurse case manager will probably be reported back to the insurance company.

Nurse case managers do not provide direct medical care.

Most insurance companies are for-profit, which means they make more by paying you less. The nurse case manager is protecting the insurance company’s interests, not yours.

As a workers’ comp attorney, one of my jobs is to ensure the nurse case manager is following the rules. Many do, but I have seen examples of nurse case managers attempting to direct treatment recommendations by trying to get the doctor to assign less limiting restrictions or avoid costly surgical options. I even had one case in which the nurse case manager’s activity was so extreme that I had to file a Motion to Remove her from the claim!

So, what exactly is a nurse case manager? What are the rules that govern them? And how can your attorney protect your rights throughout your medical treatment? The answers to these questions follow.

For a free case evaluation, contact us online or call 1-866-900-7078 today.

How Do Nurse Case Managers Play an Important Role in Workers’ Compensation?

The role of the nurse case manager is to coordinate your medical care and communicate with your doctor about your treatment plan and work capabilities. Their role is primarily important for the insurance company, not you. In fact, in my experience, some workers’ comp nurses may become a mouthpiece for the insurance company, focusing more on costs rather than what is best for the injured worker. 

Nurse case managers do not provide medical care.

They also keep track of your recovery – and this can include reporting back to the insurance company if you miss any appointments or don’t follow your treatment plan. Reports like these can hurt your chances for continued workers’ comp benefits or a maximum settlement.

It’s important to understand the true purpose and scope of the nurse case manager’s involvement – and how you can protect yourself if your rights are violated.

Limitations of a Nurse Case Manager in a Workers’ Comp Claim

Your nurse case manager is not supposed to provide you with direct medical care or pressure your doctor in any way.

Examples of prohibited nurse case manager behaviors include:

  • Directing medical care or suggesting treatment
  • Advocating for one type of treatment over another
  • Pressing for a change in your treatment plan
  • Pushing for your doctor to ease your work restrictions or return you to work prematurely
  • Advising you on any legal matters involving your workers’ comp claim
  • Interfering with your examination or treatment

A list of items that your nurse case manager should not do in regards to your care.

What Are the Rules Governing Nurse Case Managers?

Each state outlines the rules that nurse case managers should follow:

  • In North Carolina, nurse case managers must follow the North Carolina Industrial Commission Rules for Utilization of Rehabilitation Professionals in Workers’ Compensation Claims.
  • In South Carolina, the Workers’ Compensation Act and SC Code Regulations lay out rules that nurse case managers must follow when communicating with workers’ comp health care providers.

In general, nurse case managers are subject to the requirements, rules, regulations, and Code of Ethics specific to their license and certification.

When nurse case managers are hired by the employer’s insurance company, they may take on additional tasks that can impact your workers’ comp case. Here are these tasksand how you can and should control them: 

  • Attending your doctor’s appointmentsbut you can request a private exam with your doctor and instruct the nurse case manager to speak with you and your doctor after the exam
  • Speaking with your doctor about work restrictions and your ability to return to workbut it must be in your presence
  • Sending reports to the insurance adjusterbut they must send you and your attorney a copy at the same time

Your rights when a nurse case manager is involved.

Do You Have Questions About a Nurse Case Manager in Your Workers’ Compensation Case?

Communication between your nurse case manager and your treating doctor should not conflict with or interfere with your medical examination and treatment. If you are worried that your nurse case manager is trying to influence your doctor in a direction that may not serve your best interests, I urge you to talk to an experienced workers’ compensation attorney as soon as possible.

A checklist of items that may indicate that the nurse case manager is breaking the rules.

If you feel the answer to any of these questions is “yes,” consult with an experienced workers’ comp attorney immediately.

We Will Evaluate Your Case for Free

Don’t be lulled into a false sense of security that the insurance company is just watching out for you when they tell you they’ve hired a nurse case manager to help you in your recovery. Remember that they are paying the nurse case manager, and that nurse is protecting their interests, not yours. The shorter and cheaper your treatment, the more profit the insurance company likely makes.

You don’t have to take on the insurance company alone. If you are having problems with their nurse case manager, the Law Offices of James Scott Farrin can help. We’ll monitor the nurse case manager for compliance with the rules, while you focus on your recovery.

We will be your advocate and also help you with all the other aspects of your workers’ comp case, such as:

  • managing all case details and meeting deadlines
  • collecting medical records and other evidence
  • handling the insurance company
  • pursuing full wage loss benefits and payment for medical treatment

And we know workers’ comp law. The Law Offices of James Scott Farrin was named to the 2024 U.S. News – Best Lawyers “Best Law Firms” list4 and received a Tier 1 ranking (the highest) for Workers’ Compensation Law – Claimants. We have 15 offices in North Carolina and one in South Carolina and have been helping protect the rights of injured workers for more than 25 years.

We put our clients first every step of the way, and we want to help you, too. Call 1-866-900-7078 today or contact us online to get a free professional opinion on your case with no obligation.


Frequently Asked Questions

Why Do Insurance Companies Assign Case Managers?

For-profit insurance companies may hire nurse case managers to monitor the costs of injured workers’ medical treatment. The cheaper and shorter your treatment, the more money they keep.

Can I Refuse a Nurse Case Manager in a Workers’ Compensation Claim Process?

No, you cannot refuse to work with a nurse case manager in your workers’ comp case, but you do have the right to request that they be removed from your case in North and South Carolina if you feel that they are working against you. Your attorney can help you petition to have the insurance company’s nurse case manager withdrawn from your case.

What Are Some Things a Nurse Case Manager Does Not Do?

A nurse case manager must not prescribe, direct, or authorize medical treatment or attempt to influence the doctor’s opinions or recommendations.

About the Author

Casey Day practices workers’ compensation law for the Law Offices of James Scott Farrin and has experience on both the defense and plaintiff sides. She is licensed in North Carolina, South Carolina, and Virginia and is a North Carolina State Bar Board Certified Specialist in Workers’ Compensation law. Casey was honored on the “Best Lawyers: Ones to Watch” list for Workers’ Compensation Law – Claimants by Best Lawyers in America for 2021 and 2022.a Casey regularly contributes her time to helping the underserved through pro bono legal work.

aFor “Ones to Watch” standards of inclusion, visit bestlawyers.com.