Nurse Case Management Services

The vendor is required to provide case management that will ensure the coverage of the various needs of a variety of services for injured workers as well as provide the option to utilize the firm’s medical necessity review program or vocational rehabilitation services on an as needed basis.
- Service eligibility criteria
• The contractor shall accept cases for services only upon request from the city of safety and risk management department.
• The following at minimum, but not limited to, are examples of commonly used specialty areas of the city:
o Trauma management
o Orthopedic
o Physical medicine and rehabilitation
o Pain management
• The city of prefers a broad area of demographic coverage for staff assigned to this contract.
• Provide case load capacity to staff with case load availability.
- Requirements
• Initial evaluation
• Interview injured worker
• Treatment goals
• Coordination of medical treatment
• Monitor recovery process
• Communication of information
• Communication of light duty program- facilitate return to work
- Injured worker interview
• The injured worker’s medical history that includes prior accidents or injuries, health problems and medications.
• Injured worker’s current treatment plan, including therapy, proposed surgeries and estimated return to work plan, if applicable.
• The injured worker’s specific physical limitations and the degree of limitation per area identified. 
• The injured worker’s family and financial situation and any special circumstances that directly affect such status both short and long term.
• Contractor shall schedule an appointment with the attending physician, specialty physician, or attending psychologist and psychiatrist within 48 hours of assignment from city of safety and risk management department.
• Contractor shall obtain a diagnosis, treatment plan, prognosis, estimate release to transitional employment (if applicable), identify work issues such as physical limitations or release to limited hours and estimated length of disability from the attending medical provider.
- Treatment goals
• Treatment goals shall entail contact with all medical providers, including, but not limited to, the attending physician, physical therapist, specialty physicians, or the attending psychologist, psychiatrist, or counselor.
• Identify any barriers or problems that may hinder recovery.
• Identify probable period of convalescence before release to transitional employment and maximum medical improvement
• Determine relationship of interventions that the physician and other health care providers recommend. 
• Identify short term and long-term rehabilitation goals.
- Coordination of medical treatment
• Provide coordination of medical needs by the claimant, including physical therapy, durable medical equipment (DMES), medication, scheduling of appointments with medical providers, consultants, specialists, transportation to and from medical providers to include bus passes, cab vouchers, and diagnostic testing at the direction of the attending physician.
• Authorization must be obtained from the city of claims adjuster prior to authorizing any service or supply.
• Prevent duplicate or unnecessary medical services.
- Communication of services:
• As soon as practical, after an appointment, the assigned nurse shall forward the injured workers resulting work status form to the assigned adjuster.
• Provider visit and appointment results in a need for authorization, or other urgent issues arise, the assigned nurse shall call the assigned adjuster, give report, and request the authorization.
• This phone call to the adjuster does not substitute for the emailed report which is still due within twenty-four (24) hours.
• Communicate light duty availability to treating physician.
- Monitor recovery process
• Continue follow up on the recovery process as directed by the city of workers compensation claims adjuster.
- Bilingual services
• The nurse case management services, the contactor shall provide a Spanish speaking nurse or medically trained individual to accompany the nurse when using a Spanish speaking injured worker to see physicians, therapists, etc., as requested.
- Deaf and hard of hearing services
• Separate from the nurse case management services, the contractor shall arrange to provide a certified sign language interpreter to accompany a deaf or hard of hearing injured worker to see physicians, therapists, etc., if assigned by the adjuster.
- Medical necessity file reviews
• Arrangement of the material in order and summarization of the events
• Diagnoses, treatments, studies, therapies, etc., pertinent to the lines of coverage or injury applicable.
• An opinion regarding appropriateness of treatment, prognosis, and assessment of reasonable and customary charges.
- Reporting requirements
• Initial assignment report: submitted via email or telephone to the city of worker’s compensation adjuster regarding initial contact and assessment.
• Monthly reports: submitted via mail or email to the appropriate adjuster which updates the status target date for completion of each referral and recommendations with respect to continuing treatment. 
• Annual report: submitted to the city of risk management department within thirty (30) days after the end of each fiscal year (June 30th).
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: July 31, 2025