Meet Juanita Rios, MA, CRC, CCM
Juanita has over 10 years of case management experience. She holds an MA is Rehabilitation Counseling, CRC, and CCM. Juanita is committed to advocating for injured employees by collaborating with treating providers and claim adjusters to eliminate barriers to claim resolution.
“Field case management in workers’ compensation combines advocacy, collaboration, and timely intervention to address concerns efficiently and support optimal recovery and return-to-work outcomes.”
Challenge
In 2005, a *Uriah, 50-year-old firefighter, sustained a work-related injury after experiencing acute chest pain while carrying a smoke exhaust fan during a structure fire, ultimately requiring angioplasty.
Over time, his condition progressed significantly, and when case management involvement resumed in 2023, he presented multiple severe pulmonary diagnoses, including Stage 4 chronic obstructive pulmonary disease (COPD), bronchial asthma, shortness of breath, and pan lobular emphysema. He was oxygen-dependent and medically complex, requiring continuous oversight by his pulmonologist.
Despite stability due to an extensive 12-medication regimen, Uriah faced ongoing challenges, including administrative barriers, delays in medication authorization, and risk of treatment interruption. Given the severity of his condition, even a short lapse in medication access could result in acute exacerbation, hospitalization, and significant decline in health status.
Solution
During a 2026 provider visit, Juanita identified a critical gap: the treating pulmonologist’s office had limited familiarity with workers’ compensation processes, including a request for authorization (RFA) submission and utilization review requirements, creating risks for delays in medication approval.
Juanita immediately intervened by providing direct education to the provider and office staff regarding workers’ compensation processes and emphasizing the urgency of timely submissions to avoid disruption in care. Juanita also obtained medication samples during the visit to ensure the claimant maintained uninterrupted access to essential prescriptions.
Soon after, Juanita successfully secured RFAs for all 12 medications and submitted them to utilization review as urgent requests for expedited processing. Simultaneously, she maintained close coordination with the adjuster to address pharmacy access barriers, including system challenges impacting medication dispensing.
Ongoing follow-up ensured all administrative hurdles were addressed promptly, while continuous monitoring supported adherence to treatment and rapid resolution of any emerging issues.
Result
Through decisive and proactive case management intervention, all 12 medications were successfully authorized less than a month later without any interruption in therapy. Uriah maintained stability due to continuous access to medications, avoiding exacerbation of his severe pulmonary condition.
Uriah expressed significant relief knowing his medications were secured, reinforcing adherence and confidence in the care process. Ongoing coordination continues to ensure sustained stability in this high-risk case.
Most notably, Juanita’s actions directly prevented a potential COPD-related hospitalization. Uriah reported a prior hospitalization that lasted approximately 10 days; by avoiding a similar admission, the intervention resulted in significant cost savings.
By addressing administrative barriers, facilitating provider education, and ensuring uninterrupted access to life-sustaining medications, Juanita not only preserved Uriah’s health but also prevented a high-cost hospitalization. This outcome shows how skilled coordination and early intervention can significantly reduce risk, contain costs, and improve quality of care in even the most medically fragile populations.
*Name changed for privacy purposes