Health Care Management Specialist

1.

Makes an initial telephone call to the member within 24 hours of receipt of the referral (unless the Committee has requested otherwise).

During the initial call, determine if more information can be gathered immediately or make an appointment for a more convenient time to contact the member for an interview. Provide information and tips relating to the member’s issues and ensure the member is aware of relevant community-based resources.

Points often covered in the interview include:

  • An introduction

  • Information as to the goals and mandate of the JEIS program and also explains the HCMS role

  • Confidentiality and privacy expectations

  • Reason for absence (medical, work-related, other)

  • Diagnosis, current treatment, symptoms, and functional abilities

  • Any possible gaps in healthcare services that may be negatively affecting the member

  • Other resources or programs available, including their Employee Assistance Program, and how these resources can help in their recovery

  • What the member has access to within their Extended Health Benefits that may be beneficial to the member’s situation

  • The discussion may also explore the impact of the individual’s health condition on the member’s daily living and on their ability to perform their job duties.

2.

After the initial call and interview with the member, update the Committee, including any next steps and an estimated prognosis for return to work.

3.

Determine the member’s status and required actions as outlined in the table below.

Status Action
No further assistance needed If it appears the member’s medical situation is unlikely to go beyond the expected normal recovery period and there are no complicating factors, it is not likely as the HCMS you would suggest any further assistance beyond the general offer of support.
Further assistance needed If you think further assistance can be provided or more information is required to make an assessment, send out a JEIS package within 24 hours of the initial discussions and include:

  • A letter explaining the JEIS program
  • Medical forms for completion
  • Authorization forms (Medical, ICBC, WorkSafeBC).

4.

The letter within the JEIS package will indicate the date the member must return the forms to you. The initial deadline allows approximately three weeks  for the information to be returned.

  • If the information is not received by this initial deadline, contact the member again to determine the cause of the delay and to assist if there are barriers preventing the member from providing the information.

  • Send the member a second letter showing a final deadline for submitting the requested information. The final deadline is three weeks from the date of this letter. This letter is copied to the Committee.

5.

Additional medical information is often requested from the member’s treating physician or through an Independent Medical Examination (IME) in the following situations:

Situation Actions
Complexity When the initial Attending Physician’s Statement (APS) is received but, there is complexity to the medical condition, poor completion of the form, lack of clarity regarding the member’s treatment or symptoms, or inconsistencies with the member’s reported functionality.
Inconsistencies You note inconsistencies between the member’s description of their functional abilities and symptoms compared to what the current medical information on file indicates.
Request for additional medical information When additional medical information is requested, the HCMS will contact the treating physician directly and advise the member that they asked for supplemental information.
Request for Independent Medical Exam In the case of an IME, the member would be notified by the HCMS. The Committee would also be advised that a medical assessment is being arranged.

6.

As the HCMS, you also ensure copies of any assessment are forwarded to the member’s treating physician.

7.

Once all required information has been received and analyzed, the process moves to the Recovery and Return to Work phases as outlined on this website.

8.

When you believe it is likely the member will not recover and return to work during the LTD elimination period and, therefore, may progress to LTD, you may request clinical notes, specialist consultative reports, etc. Including this information at the time of LTD referral allows for a timely LTD claims decision.

9.

You must keep the Committee informed at each step of the process through different methods:

Method Actions
Email and phone Normally, at least every four weeks, although this situation-dependent. In cases where there are pending specialist’s appointments, assessments, medical procedures or expected longer-term absence, the contact may vary.
Regular meetings with the Committee Generally, it is monthly, but the timing varies from district to district. The meeting can be virtual or in person.

You provide a written report for this meeting containing a brief status update on all active files and new referrals. The report also contains updates on all active and recently closed LTD files completed by the LTD claims adjudicators. The LTD claims adjudicator may attend the meeting. The HCMS typically sends the report 1 – 2 days prior to the meeting to allow the Committee members time to review and determine if there are any questions/concerns.
Copy of all member correspondence to the Committee The exception would be the initial JEIS package or when correspondence contains confidential medical or personal information. This would include letters regarding non-contact, non-participation, suspension of JEIS files due to work-related or other issues, etc.