✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on June 26, 2025.

Case managers inherently create cost savings when performing their core activities and functions, such as managing resources or ensuring the appropriate level of care. However, the case manager’s primary responsibility is to ensure the client receives quality care and achieves optimal outcomes. Thus, CMs must balance cost-effective care with advocacy for necessary services.

Resource management

Case managers evaluate clients’ needs for resources and services and then determine the most appropriate and cost-effective ways to meet those needs. They assess the appropriateness of requested services and ensure efficient use of resources.

Appropriate level of care

Case managers ensure clients receive care at the most appropriate and cost-effective level and setting. This includes facilitating transitions to lower levels of care when appropriate, such as moving from acute care to a skilled nursing facility or home health services.

Care coordination

Effective care coordination prevents costly gaps, fragmentation, and duplication of services. Since clients are at high risk during transitions, case managers focus on facilitating clear provider communication and well-coordinated transitions to prevent costly delays and adverse events.

Utilization management

Case managers evaluate the medical necessity and appropriateness of services (e.g., determining whether medical necessity criteria are met for admission or whether a continued stay at the current level of care is justified). This process helps ensure services align with client needs while preventing unnecessary utilization and cost.

Prevention and early intervention

By identifying high-risk clients early, case managers implement interventions that prevent costly complications. For example, arranging diabetes education can prevent emergency department visits, while home safety evaluations can prevent falls and hospitalizations.

Negotiation

Case managers negotiate for services outside standard benefits when necessary to achieve optimal outcomes, such as additional therapy sessions or specialized equipment. They can attempt to arrange single-case agreements when needed services are only available out-of-network.

Content adapted from CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025) and used with permission from the Case Management Institute.