Managed Care in Risk Management

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Photograph by Ian Hooton/Science Photo Library/Corbis

Putting the “Care” in Zurich’s Managed Care.

For an injured worker, a work injury isn’t just about returning to work—it’s also about achieving maximum recovery. Studies have shown that the sooner an injured worker returns to work, even in a limited or modified capacity, the better the outcome. As of 2012, almost 200 nurses comprise Zurich’s medical management division, and their focus with any claim is to facilitate the recovery process through what is often a highly complex medical environment; returning to work is a vitally important outcome whenever possible.

“Oftentimes, the medical provider focuses on the restrictions of an injury,” says Dr. Nina McIlree, Vice President, Medical Management, Zurich in North America. “Our focus at Zurich is, ‘What are the physical capacities needed by the injured worker to get back to work, and how do we facilitate the provider and the injured worker collaborating to attain those capacities?’ This mindset is proactive and positive.”

To help accomplish that goal, Zurich nurses meet as early in the claim process as possible with the injured worker and his or her employer to talk not only about the medical issues of the claim, but also about the job’s requirements. Generally, within one day of receiving the case, the nurse has met with the injured worker, the employer and the medical provider; from that point forward, the nurse’s job is to assist the worker and the provider in getting that worker back on the job. Much of this task comes down to translating often intricate and overwhelming “medical-speak” into language everyone can understand. The nurse clarifies the condition and the care needed before moving forward to help facilitate that care.

“The medical environment is complex, fast-moving and sometimes loses the human touch,” Dr. McIlree says. “Our nurses have the unique opportunity and privilege to be able to help the injured worker navigate that often difficult process.”

After a successful pilot program, another set of Zurich nurses now take a different and unique path in helping achieve the desired outcome of a return to work. These nurses train with Zurich’s risk engineering team to understand the Americans with Disabilities Act (ADA), union regulatory issues, the specific job capabilities, and attendant return-to-work obstacles. They work directly with the claim professional—and, if appropriate, the employer—to give, in essence, a hybrid nurse/risk engineering perspective on what is inhibiting return to work. This proactive collaboration of risk engineering, claims and the nurse reviewer has proven very successful, according to Dr. McIlree.

“The nurse reviewer looks at the case from the medical perspective—‘Are there any aspects of the injury that would inhibit the worker from being able to perform these job capacities, fully or in a modified fashion?’” Dr. McIlree explains. “If not, the nurse engages in a conversation with the provider to say, ‘The employer has a job that the worker could do in a modified fashion. It appears the worker has these capabilities. Do you agree?’ It’s a unique way to merge the nurse’s medical expertise with the additional training from a risk engineering perspective.”

The closer integration of medical management with claims also helps improve efficiency and aptly demonstrates the strong teamwork that is part and parcel of the company’s “One Zurich” approach. Whether in insurance or medicine, or at the intersection of the two, it takes a village to achieve the best outcomes.

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