Duties and Types of Case Managers

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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? Not sure just exactly what a case manager does, why you need one, or what you'd be doing if you became a case manager? Here’s what you need to know.

Case Management Can Mean Different Things in Different Areas

First, you should know that what a case manager does depends on the setting in which he or she works. 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. Namely, case managers evaluate a patient’s needs and available resources. Case managers try to find the best, most efficient, economically feasible way of meeting the patient’s needs with the available resources.

And particularly for chronic, serious 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.

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. She makes sure the insurer has all the information it needs to approve payment for the hospitalization and works to prevent insurance claim denials. She communicates with the health insurer’s case manager every day or every few days.

She’s 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. She’s the one who helps the patient pick a home health company or inpatient rehab facility that’s in-network with his insurer and will accept him as a patient.

Additionally, a hospital case manager might negotiate coverage benefits between a health insurer, provider, and the patient. Here’s an example: Perhaps a patient with a chronic bone infection is healthy enough to go home from the hospital and get his IV antibiotics at home for the next three weeks. However, the patient’s health insurance policy doesn’t cover the IV drug or the equipment like IV tubing and pumps that the patient needs to receive the drug at home. The home IV pharmacy wants the patient to pay $5,000 out of his own pocket for the drug and equipment.

The case manager might negotiate with the home IV pharmacy, the home health care nursing company, the health insurer, and the patient. Perhaps she gets the patient to agree to pay a more affordable $1,000 toward the cost of the drug and equipment so he doesn’t have to stay in the hospital for another three weeks.

She also gets the home IV pharmacy to decrease the cost of the drug and equipment by $1,000. She gets the home health care nursing company to agree to pick up the tab for the IV infusion pumps at a cost of $500. She gets the health insurance company to agree to pay the pharmacy the remaining $2,500 even though it doesn’t have to because it’s not a covered benefit on the patient’s policy.

The insurer is willing to pay the $2,500 so it won’t have to continue paying the hospital for inpatient services. The home health company is willing to pay $500 for the pumps because if it doesn’t, the patient won’t come home and won’t need any home health care nursing services at all. The pharmacy is willing to decrease the price of the drug and equipment by $1,000 because making a smaller profit is better than making no money at all if the patient isn’t discharged.

Home Health Care Case Manager

A home health care case manager differs from a hospital case manager in that she often provides hands-on patient care. In addition, she 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 other visiting nurses or home health aides who also provide care to the patient.

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. She coordinates implementation of this plan with the patient, necessary service providers, and tweaks the plan when needed.

Health Insurance Company 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, she may even visit a patient in the hospital.

Her goal 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. She 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, she may limit her scope of work to patients with a specific chronic disease process. For example, if she works only with rheumatoid arthritis patients, she’s an expert in coordinating the care of RA patients and can anticipate their care needs and efficiently put in place ways to meet those needs. She can cut through red tape and may have the ability to reach beyond the covered benefits of the health insurance policy and approve items or services that aren’t actually covered by the health insurance policy but that will allow care to be delivered more efficiently and save money in the long run. She works to meet the patient’s needs while keeping an eye on the bottom line and long-term goals.

Who Does Case Management?

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.

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Article Sources

  • American Nurses Credentialling Center (Subsidiary of American Nurses Association), Nursing Case Management 500. 

  • US Department of Health and Human Services, Agency for Healthcare Research and Quality, Benefits of case management for chronic illness limited, February 2013.