Managed Medicaid is one of the most challenging areas of case management, and (due to Medicaid reimbursement,) it's one with the highest ratios of nurse case managers to members. I've done hospital case management, commercial telephonic case management, and (for 6 long months,) a Managed Medicaid program similar to yours. We encountered many of the problems that you have found, e.g. members who were difficult to find, difficult to work with, and had benefits that made it difficult for the physicians to help them. I would have liked to stay longer, but the 400:1 ratio of members to CM made it impossible to get anything done, and created a huge liability risk for us as nurses. I was involved at the start-up of the project in our state, and would hope that things have gotten better by now, but I don't know. Most of the members do need social workers more than they need nurses, but for whatever reason, the company hired more RN's than MSW's. The initial assessments that we had to do for each member did require nursing knowledge and judgment, but after that, a social worker and a clerical person could indeed have helped, assisted by a nurse, only as necessary. As an answer to your question, I would say this this is mostly the fact that you were working with Medicaid, and that most telephonic case management is quite different.