Patient Care: The Complex Role of Case Managers

Case managers can play a critical role in the success of any healthcare facility, large or small. Among the many benefits of having a case manager is their ability to effectively guide the patient through his or her stay, reduce fragmentation in care delivery, and increase the quality of services provided.

Case manager roles include:

1. Ensure Compliance

The case management team ensures compliance by preventing readmissions, determining medical necessity and patient status, and making sure healthcare facilities comply with discharge rules and patient follow-up.

2. Save Healthcare Facilities Money

Case managers have a vital impact on the financial status of a hospital or clinic by providing discharge planning of complex patients that decreases the length of stay, which increases revenue for the hospital, which is also beneficial for the revenue cycle.

 3. Work with Insurance Companies

Case managers work on the front lines by getting a patient’s hospital stay approved by insurance. They also ensure that a patient meets any medical necessity guidelines an insurance company may require. The case management team also helps with inpatient denials to facilitate either a timely discharge or assist with getting denials overturned by the patient’s insurance company.

4. Facilitate Discharge Planning

According to the Case Management Society of America (CMSA), case managers “have a unique opportunity to lead the charge in developing an individualized and comprehensive care transition plan that meets the needs of the individual across the continuum of care.” One of their main jobs is to help with the transition of care facilitation. This means that if a patient needs to go to a nursing home, special rehab clinic, or a long-term care hospital, the case manager facilitates the patient’s transition from the hospital to the new facility.

Case managers also handle other “important things,” like making sure patients are sent home with the correct medical equipment or medication.

Another important job of the case manager is to be a patient’s advocate. This means that the case manager will not “allow a discharge to occur that is not safe.” While case managers aim to decrease hospital stays for patients, they will not do so unless it is safe for the patient to be discharged.