Duties and Types of Case Managers

Nurse Visiting Patient At Home

Tetra Images / Getty Images

Has your health insurance company assigned you a case manager? Are you being seen by a case manager in a hospital or home health company? Are you a nurse who wants to become a case manager?

If you are not sure what a case manager does, why you need one, or whether you'd like to become one, here is some information that can help.

Responsibilities

First, you should know that what a case manager does depends on the setting in which they work. For example, a case manager working for a home health care company will be providing very different services than a case manager at a health insurance company, workers' compensation insurance company, or hospital.

However, there are certain things consistent across all case management roles.

Case management involves the assessment of a client's needs and the linking of that client to the available services and resources. As such, the case manager works as a facilitator rather than a provider of client services.

Particularly for chronic medical conditions, case management can result in better patient outcomes, better compliance with medical advice, and better patient self-management although there are limits to the impacts that case management can have. Here are some examples of what a case manager does in different settings.

Hospital Case Manager

A hospital case manager is usually a nurse who does both utilization review and discharge planning. Utilization review involves making sure that a patient is getting care that’s medically necessary and getting it in the correct setting.

Discharge planning is the process of predicting the patients continuing medical needs after the hospital and putting in place a plan to meet those needs. Hospital case managers are masters at organizing complex care needs across time and providers.

One of the key roles of a hospital case manager is to assess the patient's health insurance plan and to work with the insurer and multiple providers to ensure that the best care is delivered with the least financial burden.

For example, it’s the hospital case manager that makes sure a patient’s health insurance company understands what’s happening during the patient’s hospitalization.

The case manager would also make sure that the insurer has all the information it needs to approve payment for the hospitalization and works to prevent insurance claim denials. The hospital case manager will typically communicate with the health insurer’s case manager every day or every few days.

The hospital case manager is also the one who arranges for a patient to have home visits from a visiting nurse after being discharged from the hospital or to get intensive stroke rehabilitation from an inpatient rehabilitation facility. The case manager will help the patient pick a home health company that’s in-network and will accept them as a patient.

Additionally, a hospital case manager may negotiate coverage benefits between a health insurer, provider, and the patient.

Here’s an example: Say, a patient with a chronic bone infection is healthy enough to go home and obtain home antibiotic infusions for the next three weeks. However, the health insurance policy doesn’t cover the intravenous (IV) drugs or equipment for home-based care..

The case manager may end up negotiating with the pharmacy, home health care company, health insurer, and the patient. In some cases, the patient may have to pay some out-of-pocket expenses, but it will be far less than what it would cost to stay in hospital. By negotiating with all parties, the case manager can help drive down costs down.

Home Health Case Manager

A home health care case manager differs from a hospital case manager in that the manager often provides hands-on care. In addition, the case manager coordinates the services of other members of the health care team and caregivers, communicates with the health insurance company, communicates with the patient’s physician, and supervises visiting nurses and other home health aides who provide support.

With input from the patient and family, the home health care case manager develops that patient’s plan of care and presents it to the patient’s physician for final approval. The case manager will also coordinate the implementation of the plan with the client and service provider and make tweaks to the plan when needed.

While home health case managers are often nurses, many are not. It is important, therefore, to establish whether the home health company you're hiring provides nursing care or basic home assistance.

The laws regulating home health case management vary by state, with some (like California) requiring certification and others (like Massachusetts) not.

Health Insurance Case Manager

The health insurance company’s case manager receives information from hospital case managers, home health care companies, physician’s offices, social workers and other health care providers. Depending on the insurer and the location, the case manager may even visit a patient in the hospital.

The goal of health insurance case management is to make sure the patient is getting medically necessary care, quality care, and that the care is being delivered as efficiently and economically as possible. The case manager also anticipates the patient’s future health care needs and tries to put in place mechanisms to meet those needs as efficiently as possible.

In some health insurance companies, the job may be focused on a specific chronic disease. For example, if working with people with HIV, the case manager would ensure that monthly medications are received properly, the optimal adherence is achieved, that routine blood tests are scheduled, and any side effects or complications are noted so that providers can be coordinated.

Within this context, any shortcoming in case management can have direct and potentially dire consequences for the patient.

Becoming a Case Manager

Case management is usually done by nurses, but not always. Depending on the setting, another type of professional may provide case management services. For example, the person providing case management services in a substance abuse rehab facility might have a background in substance abuse counseling. It’s not uncommon for case management to be done by medical social workers.

Hospital case managers must hold a license or certificate in a health or human services discipline (such as nursing or social work) and have field experience of 12 to 24 months before official certification can be obtained.

According to the Bureau of Labor Statistics, medical and health services managers in the United States earned a median annual salary of $99,730 in 2018.

Was this page helpful?

Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.