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?
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If you are not sure what a case manager does, why you need one, or whether you'd like to become one, this article will explain some basic information that you need to know.
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 healthcare 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 patient's continuing medical needs after they leave 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 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 healthcare 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.
Hospital case managers are sometimes referred to as care coordinators or patient advocates, depending on their specific role. In any case, they can serve as a valuable resource for the patient, the hospital, and the patient's health plan.
What Is a Hospital Patient Advocate?
Home Health Case Manager
A home healthcare 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 healthcare 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 healthcare 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 only basic home assistance.
The Rise of Home Healthcare in the US
Health Insurance Case Manager
The health insurance company’s case manager receives information from hospital case managers, home healthcare companies, physician’s offices, social workers and other healthcare 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 healthcare 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.
The Role of Disease Management in Healthcare
Becoming a Case Manager
Case management is often 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.
If you want to become a case manager, you'll need to understand the education, licensure, and certification requirements in your state and for the particular organization where you hope to work (ie, an insurance company, a hospital, a home healthcare company, etc.). In most cases, you'll need a background in a field such as nursing or social work, but the specifics will vary depending on the job you're seeking.
Those underlying professions have their own licensing requirements, overseen by state medical boards and regulatory departments. Since medical licensing is done on a state-by-state basis, this can get complicated if the organization employing the case manager has clients in multiple states.
For example, nurse case managers must maintain their nursing license in any state where they are providing services. Depending on the scope of the organization that employs the nurse case manager, this may involve obtaining multiple state licenses, or participating in a multi-state compact in which states recognize the nursing licenses provided by other states.
In addition to the underlying education and professional licensure, most states and employers will require certification in case management. For example, you may need to get a CCM (Certified Case Manager) certification from the Commission for Case Manager Certification, or an ACM (Accredited Case Manager) certification from the American Case Management Association.
If you're a social worker, your certification might be as a Certified Social Work Case Manager (C-SWCM) or a Certified Advanced Social Work Case Manager (C-ASWCM), which can be obtained from the National Association of Social Workers. (Note that Commission for Case Manager Certification and the National Association of Social Workers have a collaborative agreement that allows social workers to take the CCMC certification exam without an additional fee).
You'll want to clearly understand the education, experience, licensure, and certification requirements for the job you're seeking, as they will differ from one state to another and from one job to another.
According to PayScale, the average nurse case manager in the United States earns $72,655/year. But for case managers who are not nurses, average salaries tend to be lower, with the overall average income for a medical case manager at a little more than $53,000 as of early 2022.
Summary
A case manager's job differs depending on whether they work for a hospital, home health agency, or health insurance company. But in general, case managers ensure that patients receive well-coordinated, medically necessary care, and that all involved parties (health plan, medical providers, and the patient) are kept in the loop and on the same page.
A Word From Verywell
If a case manager has been assigned to your medical care, they can be a helpful resource in terms of making sure that you're receiving the care that you need and that your health insurance plan is being kept updated on the specifics of your treatment. They can also help to coordinate care and ensure that you stay healthy after a hospital stay, to reduce the chances that you end up needing to return to inpatient care.
Is Healthcare a Satisfying Career Choice?
FAQs
What are the roles and responsibilities of a case manager? ›
Case Manager responsibilities include:
Coordinating and providing care that is safe, timely, effective, efficient, equitable, and client-centered. Handling case assignments, draft service plans, review case progress and determine case closure. Helping clients achieve wellness and autonomy.
- Brokerage model. This is an office-based case management system in which the patient or client meets with the case manager a few times to resolve issues. ...
- Intensive case management. ...
- Clinical case management. ...
- Strengths-based model.
The case management process consists of five parts: assessment, treatment planning, linking, advocacy, and monitoring.
Can you identify 3 major skills the case manager should have? ›It is important that case managers solve these problems. The case manager's ability to provide safe, efficient, and competent services depends heavily on their skills in problem-solving, clinical reasoning, and critical thinking.
What is the most important role in case management? ›The fundamental ingredient to case management is the planning of care, which results in a care plan that essentially is the roadmap for a given patient/client to navigate through.
What are the top 3 qualities a case manager should have? ›Case managers also work as part of a team with other doctors, nurses and specialists to provide the necessary care for the patient. Active listening, reliability and problem-solving are among the qualities of a case manager that lend themselves to better collaboration.
What are the 9 best practices of case management? ›- Tip #1: Organise your case files. ...
- Tip #2: Maintain a customisable checklist. ...
- Tip #3: Prioritise your tasks by case. ...
- Tip #4: Assign and schedule tasks. ...
- Tip #5: Follow up on tasks. ...
- Tip #6: Use templates for routine correspondence.
- Hospital case manager. ...
- Home health case manager. ...
- Registered nurse case manager. ...
- Developmental disabilities case manager. ...
- Health insurance case manager. ...
- Substance abuse case manager. ...
- Child case manager. ...
- Academic case manager.
- Three Key Principles for Effective Case Management.
- Principle #1: Building Trusting Relationships.
- Principle #2: Using Evidence-Based Practice.
- Principle #3: Empowering Your Client.
Case management is guided by the ethical principles of autonomy, beneficence, nonmaleficence, veracity, equity, and justice.
What are examples of case management? ›
Case management example
An elderly patient who recently suffered a stroke might be assigned a case manager at their hospital to ensure they get the ongoing care they need. In this situation, the case manager would act as a liaison between the patient and their health insurer.
Within each component, case managers must perform all eight essential activities with direct client contact (assess, plan, implement, coordinate, monitor, evaluate, outcomes, general tasks).
What does a case manager do on a daily basis? ›Your responsibilities and daily tasks will depend on your specific client or employer. However, in general, case managers oversee research and help maintain and advocate for the health and wellness of their patients. Case managers typically act as the link between a patient and healthcare or social services providers.
What skill is needed for a case manager? ›Case managers must possess good time management skills to multitask, manage schedules and appointments, and meet deadlines. They must always keep contact lists, reference materials, and resource information easily accessible.
What 3 types of skills do all managers need? ›- Technical skills.
- Conceptual skills.
- Human or interpersonal management skills.
Focus on assessing needs, referring to services and coordinating and monitoring on-going treatment. Case manager coordinates services provided by a variety of agencies and professionals.
What are the objectives of case management? ›The primary role of case managers has two objectives to achieve while assessing: Identifying the Member's key problems to be addressed, as well as individual needs and interests. Building a complete case management plan of care that addresses these problems and needs.
What are the leadership styles of a case manager? ›- Critical thinking and problem-solving. As a case manager, you'll constantly be expected to solve problems or initiate changes to cases. ...
- Time management. ...
- Communication.
Case management programs must be evaluated for effectiveness in reaching the desired outcomes and goals. This is done by collecting, analyzing and reporting data. Two ways to evaluate the effectiveness of the case management program are to conduct surveys and to measure outcomes.
What is case management tools? ›A case management tool is a software solution that allows organizations to automate case workflows and processes, store and access a great deal of client information, and drive case resolution for boosted customer satisfaction.
What are the 4 components of case work? ›
The four components of social case work are person, problem, place and process. The person is called the client in social work terminology.
What is case management style? ›A case management model is a set of guidelines, processes, and procedures for case managers to most effectively deliver the appropriate services and care to their constituents.
What is case management concepts? ›Case Management Concepts (CMC) is a consulting and educational health care company that provides services both nationally and internationally in the field of case management and related topics.
What are the goals of case management in social work? ›Social work case management is a method of providing services whereby a professional social worker assesses the needs of the client and the client's family, when appropriate, and arranges, coordinates, monitors., evaluates, and advocates for a package of multiple services to meet the specific client's complex needs.
What questions should a case manager ask a client? ›“What are your expectations for our time together today?” “How can I help you with that?” “What was different then?” Do you think that was the best way to handle that situation?
What not to do as a case manager? › Case managers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility.
What is the best thing about being a case manager? ›“Flexibility and work life balance.” “This is a great career for dynamic and high energy people.” “Very rewarding and every day is different.” “If you like a challenge, are good at planning and can think outside the box then case management can be a very rewarding career move.”
What are the four things managers must do? ›Originally identified by Henri Fayol as five elements, there are now four commonly accepted functions of management that encompass these necessary skills: planning, organizing, leading, and controlling.
How do you answer what type of manager are you? ›- Consider the management style of previous supervisors. ...
- Think about what makes you a good manager. ...
- Determine what skills you believe a good manager should have. ...
- Figure out which type of management style you have. ...
- Tell a story including a specific management style.
A social worker directly provides some needed services to clients and offers referrals for other services. In contrast, a case manager will act as a plan developer and coordinator to connect clients to the services they need to overcome life challenges.
What is the difference between the roles of a case manager and a care manager? ›
Role: Care managers focus on ensuring that patients receive high-quality care and that their needs are met, while case managers focus on advocating for clients, coordinating services and resources, and helping clients navigate the complex healthcare system.
What are the 8 responsibilities the case manager does? ›Monitors cases by verifying clients' attendance; observing and evaluating treatments and responses; advocating for needed services and entitlements; obtaining additional resources; intervening in crises; providing personal support. Maintains clients' records by reviewing case notes; logging events and progress.
How do you describe case management experience? ›Working with specific clients, helping them find and use available services, and managing the documentation of the service relationship is all considered case management experience.
What is an example of a case management situation? ›Case management example
An elderly patient who recently suffered a stroke might be assigned a case manager at their hospital to ensure they get the ongoing care they need. In this situation, the case manager would act as a liaison between the patient and their health insurer.
A case manager, also referred to as a nurse case manager, is a healthcare professional who coordinates the overall care of individual patients.
What is the role of a caseworker? ›Caseworkers Overview & Description
Provide patients with information and counseling, and make referrals for other services. May also provide case and care management or interventions designed to promote health, prevent disease, and address barriers to access to healthcare.
Areas commonly evaluated by the social work case manager include mental health status; preexisting health or mental health problems; an appraisal of the client's needs and the resources of the client's informal support system, including family members, friends, and organizational memberships; social role functioning; ...
How is a case manager a leader? ›Case managers are leaders, and there is a difference. Managers manage systems; leaders lead people. Case managers do both; they manage cases (a number of clients) and lead, or guide, people. Leadership is one step up the ladder of professional growth and development.
Why is a case manager a good job? ›Case managers have a vital role in medical and social service accessibility. They are in charge of coordinating resources and services to help achieve holistic well-being for their clients. Individuals who are organized, meticulous and people-oriented may find case management to be a rewarding career path.
Which is the role of a case manager and a healthcare organization? ›Case managers oversee everything that happens to patients from the moment of admission, throughout treatment, and up to discharge from a hospital or another healthcare facility. These professionals provide guidance for the long-term care of patients, which includes decision-making about any important treatment options.
What is a case manager in simple terms? ›
Definition of Case Management
Case managers are healthcare professionals who serve as patient advocates to support, guide and coordinate care for patients, families and caregivers as they navigate their health and wellness journeys.
- Workload: ...
- Bearer of bad news: ...
- Paperwork: ...
- Difficult clients: ...
- Compassion fatigue: ...
- Comparatively low salary: