Telephonic Case Management

Our telephonic case-management service brings to bear a team of expert nurses to help workers achieve the most efficient and effective recovery and return to work. At any point in the life of a claim — from the earliest report until well after the claim is mature — a nurse can help workers achieve the best outcomes and, in turn, reduce time away from work and medical spending.

Field Case Management

When a case manager’s ability to remotely oversee a case is stretched, our field case managers are available to direct the best possible outcomes for the most complex cases. Even difficult, high-dollar cases can be made less severe through timely, well-orchestrated coordination of care.

Ask a Berkley Nurse

The purpose of the Ask a Berkley Nurse (AABN) program is to provide a range of services that can assist in management of cases and in the recovery of injured workers. Foremost, we provide immediate advice on how to treat injuries and determine whether more attention is needed. Our call-center nurses provide a first line of evaluation on any first notice of loss incidents and offer an instant resource for adjusters facing clinical questions. The AABN program is designed to provide an initial review of all claims, thereby allowing for an early intervention. AABN also handles medical questions that adjusters might face such as how medicines might interact or how laboratory results should be interpreted. The early intervention and quick triage made possible by the AABN team can help adjusters identify workers who might require additional resources to put their recovery on a proper course.

How It Works

  • A triage nurse can assess an illness or injury, flag emergencies, determine the proper routing of cases, direct an adjuster to the most appropriate level of care and facility as well as make suggestions to the adjuster on a general course of treatment for a low-risk patient.
  • Nurses strive to make instant responses to adjusters’ calls. If a nurse is not available, the call is moved to a priority queue and returned as soon as possible.
  • Our Legal Medical Review team of certified legal nurse consultants will dig into your case to provide the kind of deeply sourced recommendations that are necessary to successfully navigate complex legal matters. Our skilled team has the necessary clinical knowledge as well as a solid track record of working through legal matters. Together, these attributes make our legal medical review indispensable.

Utilization Review

Monitoring the clinical appropriateness of an injured worker’s treatment is key not only to a speedy and successful recovery but also to holding down medical spending. Our team of nurses and physicians stands ready to evaluate your claims for the best possible treatments. Whether it is before, during or after a course of treatment, our UR team can help ensure the most appropriate and standards-compliant procedures are reimbursed.

How It Works

  • Our medical director oversees a team that helps guide clinically appropriate care and maintain compliance with a range of jurisdictional requirements.
  • The UR process is draws upon Official Disability Guidelines and other widely respected protocols for driving the best clinical decision-making.

Independent Medical Exam

Our independent medical exams are foundational to ensuring injured workers are properly diagnosed and treated. This not only protects the patient from unnecessary or perhaps harmful care, it also saves unneeded spending and limits liability in cases where the cause and effect of an injured or ill worker's case are in dispute.

Peer Review

We provide a comprehensive peer-review program that matches like-to-like providers for jurisdictions in which doing so is required.

Radiology Review

One important service is a review of radiology readings to ensure a proper diagnosis of an injured worker's condition. This key service illustrates the level of depth of our approach to ensuring an injured or ill worker is properly diagnosed to allow for the most appropriate and effective treatments. A team of skilled radiologists is on hand to offer an oftentimes critical second opinion for complex cases. This helps avoid unnecessary and perhaps risky treatments and more timely attention to the most pressing issues that injured or ill workers face.

Hospital Review

An audit of a hospital or similar medical care facility is an important part of ensuring workers can obtain the best-quality care that will speed their recovery. We document and evaluate a range of critical statistics about a facility to hold providers accountable for furnishing injured or ill workers with care based on the highest standards.

Medicare Set Aside

Our Medicare Set Aside (MSA) team guides you though this complex process and helps apportion the right level of funding for future care. We take seriously our commitment to offering the most accurate forecast possible for the future cost of medical treatments for an injured worker. This is important because Medicare must not pay for treatments that come from an event such as a workplace injury. Rest assured our team has deep experience in how to complete MSA evaluations and makes solid recommendations.