What do Case Managers do?

kTIE · Jun 10, 2007

Okay, typically I start with my census, looking at the dx, patient;s age and insurance company. I need the dx to plan whether it will be complex ( intracerebral bleed ) vs possible routine ( hip replacement or knee replacement). I look at the age because age is a factor in whether I will need to eval for possible dcp to snf ( i.e. hip fx and pt is 89 yrs old, signals SNF or TCU for rehab )

Insurance is important because all of the following have different problems and issues: a) cash account, b) Medicare or c) Medicaid.

Cash account need: social work intervention for dc planning and also this will more likely be a difficult case no matter what the other factors involved. Medicare case require a manditory LOS of three days for skilled, so if it is a ...let say knee replacement, I know it will be three days before I can transfer to a snf vs home with DME. Medicaid is difficult due to the re-imbursement to the doc, and SNF's usually do not take a patient for rehab with just this as a payor, so other problems ensue with this type of payor.

Usually after evaluating my census, I attend rounds on the floor ( a common occurance as more hospitals are realizing the importance of rounds.

Then I interview the patient and ask the nurse and other disciplines about their interventions and information regarding the patient. Then I make my calls to insurance companies and doctors ( for orders, transfer status, notification of delays or other problems ) Then I make transfer arrangements for all pt's going to other facilities.

This is a synopsis of my day......not hour to hour.

Hope this helps.

dria · Jun 12, 2007

as with any specialty, there are different areas....i work in an outpatient setting...

i start my day by checking emails and voicemail messages. then i look at my caseload. first i call the pts that have been recently discharged from the hospital to make sure discharge needs have been met: discharge instructions were given and understood, ordered prescriptions filled, home health visits scheduled, equipment and supplies delivered, follow up appointment with md scheduled. if anything is missing, i assist the patient in obtaining what is needed. i also make sure the patient understands and follows their plan of care.

i then make outreach calls to pts who have high dollar claims, again to make sure their care needs are met. i also screen for mental health and social needs and make appropriate referrals. based on a pts particular diagnosis, i may refer to internal or external disease management programs.

of course, along the way, i take incoming calls and fight fires as needed.

you may find the case management society of america website helpful: www.cmsa.org

good luck on your project, and feel free to pm me if you need additional info

st4wb3rr33sh0rtc4k3 · Dec 20, 2007

Thanks for the tips and the website. I have an offer at the current hospital I work for, but I can't apply till April. So I want to do a little research to see if it is what I really want to do.