Hospital Case Manager!


Hello everyone,

I am overwhelmed over the news that I was selected to become Hospital Case Manager! I have been yearning to leave bedside nursing for the last year and just applied to this posting internally on a whim - but I did spend time with my floor Case Managers quite a bit over their overall day and job satisfaction.

I worked on Oncology floor for 4 years now, mostly as a Charge RN but we do have our own patients in this hospital! I really wanted to ask 2 questions:

During interview I was told the hospital uses Interqual and Milliman and that I will be expected to use them so can anybody give me insights /tips / advise on my first day what to expect?

Also how are Case Managers evaluated if Drs are the ones running the show on decisions to admit/everything?

I forgot to add, I will be Case Manager for an Orthopedic/Surgical floor which is giving me concern coming from Oncology.. I am quick learner and such but will I be OK with this change?


138 Posts

It will be a learning curve, but I am sure you will be fine. Btw, physicians give orders based on our recommendations....most of the time they give us whatever we think we need... Best of luck to you!


121 Posts

You will get orientation! Basically Interqual and Milliman are both programs to categorize patients admission necessity vs level of care.. as a Case Manager in a hospital you are basically planning everyone's exit out the door once in! Its fun and challenging.

Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr. Has 15 years experience.

OP: You will not need to be a former Ortho staff nurse to perform well on an ortho floor. You will need a lot of resources (connections and access to money) and some luck. Ortho floors are tough!!!

I worked inpatient Case Management to include on an Ortho floor. You will be making arrangements for patient to get medications, equipment, and placement (if needed) prior to discharge and it is not easy unless some other department will be helping you (I worked one hospital where nurses in another department dealt with placement issues freeing CMs up to deal with everything else). The problems you may encounter will be based upon insurance coverage.

Many people have insurance coverage that is a joke! For example, their insurance will not cover the medications the patient needs for discharge or will only cover part of it and the patient has to pay out-of-pocket costs near $1000.00 or more!!!! If your patient is rich, it is not a big deal. However, you will run into those that fall into the middle or who are living just-above poverty that cannot afford to pay ridiculous costs for medications and have no resources to assist him/her with paying for the medications. Despite this, you will be expected to work-some-magic to discharge the patient safely and on-time. This latter aspect of case management (discharging patients safely and on-time) you will find is one of the most important and stressful part of your new job.

Thus, during orientation be sure to ask your department/preceptor what resources you will have to get such patients out on time. Maybe your charity department is good? Maybe there are program in the community that can help cover patients who cannot afford medications or equipment?

By the way, give yourself at least a year before you decide if Case Management is right for you because typically the learning curve is so high, a year of full-time work is needed before a new CM feels comfortable in his/her position. Good luck. :)