Case Management Focus: Building Good Working Relationships with Claims Adjustors


Sarasota, FL ( -- As a long-time nurse case manager who worked in workers' compensation, I learned early on that the Claims Adjuster was a pivotal person to build a relationship with if I wanted the case to go well. The Claims Adjuster is responsible for ensuring the case follows the State's rules where the claim is made. The Adjuster must be updated on every aspect of the case and approve treatments, 2nd options, and the need for diagnostic tests, procedures, and resources. Proactive communication lets them know what is happening and provides clear directions on the case. They also ensure the injured worker receives their payment in a timely manner.  

By communicating and explaining the rationale for the plan of care, issues, or setbacks, the Adjuster can know the case is on track. The worst thing you want to happen is for the claims adjuster to be blindsided by something they did not know about your case. 

Getting permission to move forward allows you to keep the lines of communication open. I always ask the Adjuster how they want to receive information, by email, phone call, or in the notes section of the file. Everyone has their communication preferences, so find out what works best for them and try to meet their preferences. On a complex case, I might ask to meet weekly if the case has a lot going on. Again, use your discretion and be proactive. 

A good working relationship with the Adjuster can make or break a case, so keeping them informed and advised of any issues is essential as they arise. Communication with all stakeholders is vital, so touch base with all so everyone is on the same page and that you are on top of things. 

An outcome case managers can claim is that keeping all lines of communication open with the injured worker, the claims adjuster, the employer, and the treatment team, is unnecessary attorney involvement. According to Milliman, a company that set clinical guidelines in the workers' compensation space, claims with attorney representation take 2.1 times longer to close and cost 2.3 times more than claims without an attorney. Attorney involvement heavily impacts indemnity costs 3.5 times higher than claims without an attorney. 

Also, having a good working relationship with the claim's Adjuster can ensure requests for tests, equipment, therapy, transportation, and many other recommendations are approved promptly. Doing so builds trust with the injured worker and providers and shows that you have a handle on the case and are moving the case forward in a proactive manner. 

Gaining the injured workers' trust helps make the injured worker more involved in their care. It can help them be receptive to treatment and accept return-to-work options such as light duty and other strategies to ensure case progression. This is another key outcome case managers strive to achieve. 

How have you built good working relationships with the Claims Adjusters you have worked with? Share any tips you have found helpful in the comment section so we can all 'get smarter.' 

Thanks for reading. Have a good week.

Reference:  How Does Unnecessary Attorney Involvement Impact a Workers Compensation Claim?




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