Duties and Types of Case Managers

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, 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.

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.

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 that 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 to keep costs lower.

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.

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.

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.

Becoming a Case Manager

Case management is typically 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.

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 $72,983/year in 2023. 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 less than $56,000 as of 2023.

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.