Workers' Compensation Case Management Checklist Template
Ensure seamless and compliant workers' compensation claims handling. This checklist streamlines your case management process, minimizes errors, and maximizes efficiency-from initial report to final resolution. Download now and simplify your workflow!
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Initial Intake & Assessment
Steps for gathering initial information and assessing the injured worker's condition and needs.
Employee Name
Employer Name
Date of Injury
Description of Incident
Employee ID
Body Part Affected
Witness Statements (if applicable)
Medical Management
Tracking medical treatment, appointments, and reports, ensuring proper care and documentation.
Date of Initial Medical Evaluation
Physician's Diagnosis and Treatment Plan
Number of Physical Therapy Sessions Scheduled
Uploaded Medical Report (e.g., MRI, X-ray)
Physician's Opinion on Return to Work
Next Medical Appointment Date
Notes from Medical Provider (e.g., progress, concerns)
Benefits Administration
Managing wage replacement, medical payments, and other benefits eligibility and payments.
Claimant's Average Weekly Wage (AWW)
Benefit Payment Amount
First Benefit Payment Date
Last Benefit Payment Date
Total Benefit Payments Made
Benefit Payment Frequency
Payment Method
Benefit Payment Notes
Communication & Coordination
Maintaining consistent communication with the injured worker, employer, medical providers, and legal representatives.
Date of Communication
Communication Method
Summary of Communication
Recipient
Contact Person (if applicable)
Phone Number (if applicable)
Notes/Follow-Up Actions
Return to Work Planning
Developing and monitoring a return-to-work plan, including modified duty options.
Date of Initial Return-to-Work Discussion
Modified Duty Available?
Description of Modified Duty Restrictions (if applicable)
Percentage of Work Available (if modified duty)
Scheduled Return-to-Work Date
Communication with Employer Regarding Return-to-Work Plan
Return-to-Work Plan Approved?
Date of First Day Back to Work
Legal & Regulatory Compliance
Ensuring compliance with state workers’ compensation laws and regulations.
Claim Filing Date
State Jurisdiction
Claim Number
Applicable Statute of Limitations
Summary of Legal Review/Consultation
Date of Legal Consultation (if applicable)
Case Closure & Finalization
Steps for formally closing the case and documenting final outcomes.
Case Closure Date
Summary of Case Outcome & Resolution
Final Case Status
Total Benefits Paid (USD)
Case Manager Signature
Final Settlement Agreement (if applicable)
Notes Regarding Closure (e.g., outstanding issues, future considerations)
Record Keeping & Documentation
Maintaining accurate and complete records of all case activities.
Case Notes
Document Creation Date
Scanned Documents (e.g., medical reports, correspondence)
Page Count of Case File
Document Storage Location (Physical/Digital)
Last File Review Date
Case Management Screen Recording
See ChecklistGuro's Case Management in action! This screen recording demonstrates how our BPM platform simplifies case tracking, task assignment, and overall process control. Learn how to improve efficiency and reduce errors with ChecklistGuro. #CaseManagement #BPM #ChecklistGuro #ProcessAutomation #Workflow
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