By Jeanie Davis

In today’s hospitals, the role of case manager has expanded greatly as regulatory demands have increased. Case managers play a pivotal role in their hospital’s bottom line, ensuring the hospital receives reimbursement (and avoids penalties) from insurers and the Centers for Medicare & Medicaid Services (CMS).

Case managers in large hospitals have moved into C-suite roles, where they can greatly influence the hospital’s processes and procedures to improve the patient’s experience and outcome. They also can address payer and regulatory issues.

It is a much broader role for case management, which always has attracted people with an innate nature to help others, says Vivian Campagna, MSN, RN-BC, CCM, the chief industry relations officer for The Commission for Case Manager Certification.

“Nurses, social workers, therapists, pharmacists, and physicians come to this profession because they want to do the right thing,” she explains. “They want to help people get the best healthcare possible.”

Affecting the Bottom Line

In today’s hospitals, case managers are responsible for ensuring evidence-based patient care is delivered appropriately, with a good outcome. Case managers must be “lifelong learners,” always aware of the latest treatments, therapies, and applicable regulations, says Campagna.

The case manager is at the bedside, explaining treatment options to patients and families so they can navigate the confusing maze of healthcare, she adds. “They’re given so much information, so many options, so much to consider, it gets overwhelming,” she explains. “The case manager is the person helping them sort it all out.”

A strong ethical sense is key to a case manager’s professionalism, Campagna adds. “One of our most important principles is that the patient comes first. We act in the best interest of the patient at all times, even when this can involve a conflict within the hospital. The case manager must determine the best options to handle the situation, advocating for the patient even when it’s difficult.”

In this situation, case managers identify evidence-based data to support the better option, she explains. “With those data, they may be able to sway a decision.”

Case managers must understand value-based care, Campagna adds. The case manager is a team leader who will go to the physician or the team to identify priorities in a patient’s treatment plan, and accelerate the pace. “The case manager understands the need to move along in a timely manner,” she explains.

Preventive care programs are part of the Affordable Care Act, designed for at-risk populations who have costly chronic conditions such as asthma, COPD, diabetes, depression, and heart failure. Case managers can make a significant impact by motivating patients to improve their health, which will reduce hospitalizations.

“Ability to think creatively” is a key trait in a case manager, adds Campagna. “We work with insurance benefits, and sometimes benefits aren’t sufficient. The creative case manager will find alternative ways to do it — community resources, friends, neighbors who can provide services without cost. The creative case manager will organize that.”

Ready for the C-Suite?

Many case managers enjoy the day-to-day interactions with patients and families, and want to stay in that realm. Others are drawn to the C-suite, where they can influence strategic planning and administration, says Holly Worsham, DNP, MSN, RN, a consultant and vice-president at Kaufman-Hall.

Executive-level case management positions are available at many large hospitals and healthcare systems. “They are looking for business skills and higher education in those case managers, either an MBA or MSN,” says Worsham. “A lot of nurses have been leaning toward MBA so they have well-rounded business acumen.”

At the C-suite level, case managers can help develop strategies that meet regulatory and hospital goals. “Having a case manager in the executive level helps guide the C-suite and sets the processes in place to meet CMS expectations, and help the hospital’s bottom line,” says Campagna.

“In many ways, CMS is trying to get hospitals to operate on a 24/7 basis, instead of a weekday schedule,” she adds. “Value-based care is about providing services when needed. Case managers are good at taking data and sharing it with administration to support changes in hospital structure and processes. They can make a real contribution in that regard.”

Enhancing Professional Growth

Certification is part of professionalism, Campagna says, as it shows competency and proficiency. “Employers respect certification, as it shows demonstrated expertise. Mentoring is also essential to help professionals from a broader range of disciplines who are entering the profession to understand the nuances of care coordination and how to do it best,” says Campagna.

Worsham is an advocate for virtual mentoring via LinkedIn and professional organizations. “People who have been at one hospital for a long time can benefit from outside influences if they want to expand their knowledge base and grow professionally.”

She adds: “Mentoring helps both the mentor and the mentee strengthen and challenge the status quo. Often, people who work at bedside aren’t aware there are so many other career paths open to them.” She encourages case managers to join their professional organizations, or reach out to colleagues on LinkedIn. “People are very open, very friendly; they want to help,” she says.

Virtual positions are giving case managers greater options for career advancement, Worsham adds. “In some cases, you will have to relocate for a leadership position. But there are more and more positions that allow case managers to work remotely.”

The major payers provide virtual case management, she explains. “Home health agency corporations are providing remote and community-based case management. Some companies provide virtual nurses who handle nonclinical activities, such as quality and case management functions.”

Consulting is another option, which exposes case managers to multiple facilities and health systems across the country, Worsham adds. “That’s the beauty of being a nurse — there are a million different options, many of which you maybe didn’t even know existed.”