Case Manager is a role that over the last 25 years has morphed into a position that has a critical impact on the bottom line. It is a position that is, usually, filled with an RN or social worker with extensive clinical experience. This clinical experience coupled with training on utilization management and discharge planning principles results in a professional who can:
– determine the appropriate admission status for patients
– support the need for acute care admissions by providing clinical reviews to third party payors
– appeal admission and continued stay denials (RAC has made this even more critical)
– identify the appropriate discharge plan for the patient, including those with no funding, illegal immigrants, etc.
– assure and document that patient’s are given a choice of home health agencies, SNFs and hospices
– identify the over- or under- utilization of medical resources
– effectively communicate with patients/families, physicians, nursing, all hospital disciplines and insurance companies
– monitor compliance with nationally recognized standards of care and intervene as appropriate
– provide information to physicians to assist them in documenting with greater specificity
– monitor and report vendors who do not adhere to corporate compliance policies
– coordinate interdisciplinary patient care conferences -participate in multiple performance improvement initiatives
– provide education to physicians and nurses on all the above
– distribute and explain the Important Message letters to Medicare beneficiaries (including Medicare Advantage plans and when Medicare is a secondary payor)
– performs “other duties as assigned”….. Case Managers accomplish all this with patient ratios of 20-25:1. One of the major challenges that face case managers today is “other duties as assigned”. With the multitude of changes in healthcare that affect reimbursement, case managers have acquired many new responsibilities that require our expertise. But we are often given tasks that do not require our expertise and pull us away from the critical tasks that do. The challenge for all case management leaders is to help administrators realize that case managers should not be given a multitude of other responsibilities just because we’re reviewing the medical record or “we have to talk to the patient’s anyway.” They will get much more “bang for their buck” when they utilize the skills and expertise of their case managers for those duties that only a case manager can perform and assign the clerical responsibilities to positions that don’t require those skills and make lower salaries.