Roles and functions of case managers in various settings

Many of the case management roles are the same no matter the setting, such as patient advocate, assessor, and educator. Other functions are specific to a particular setting or settings. Below is a list of setting where Case Managers practice, as well as the primary functions of Case Managers in that setting.

In the physician’s office, clinic or other pre-acute setting, the role is geared toward prevention through:

  • Wellness programs
  • Screenings
  • Health risk assessments
  • Risk-reduction strategies
  • Telephonic triage
  • Disease management
  • Facilitate access to services
  • Referrals to community based resources
  • Coordination of medical and social services
  • Ensure patient knowledge and compliance with treatment 


  • Utilization Review
  • Discharge planning
  • Resource management
  • Coordination of care among all team members
  • Transition to post acute care

Acute Inpatient Rehabilitation:

  • Coordinate interdisciplinary team (IDT) meetings
  • Verify benefits and authorization of services
  • Facilitate Referrals
  • Discharge planning
  • Utilization review

Payer-based setting (Insurance Company):

  • Liaison between providers and insurance company
  • Coordinate care
  • Ensure appropriate care
  • Negotiate for services
  • Monitor for compliance with treatment plan
  • Ensure appropriate level of care and care setting
  • Educate on healthcare benefit
  • Utilization management
  • Discharge planning

Palliative care, home care and hospice case managers combine the role of caregiver with case manager.
Along with hands on nursing responsibilities they also:

  • Act as liaison with providers
  • Communicate with treating physicians
  • Provide patient and family education
  • Assess for and coordinate additional services and DME

Workers Compensation Case Management focuses on vocational activities, working with the employer to get the employee back to work. The Case Manager will:

  • Facilitate communication between employer, claims adjuster, attorneys, union representative, state administrative agency and providers.
  • Coordinate care between multiple healthcare providers
  • Monitor progress
  • Utilization review
  • Obtain precertification when necessary
  • Perform job analysis
  • Accompany injured workers during physician appointments

Following is a list of related definitions from CCMC’s Glossary of Terms

Community-Based Programs – Support programs which are located in a community environment, as opposed to an institution setting.

Appropriateness of Setting – Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.

Coordination – The process of organizing, securing, integrating, and modifying the resources necessary to accomplish the goals set forth in the case management plan.

Level of Care – The intensity of effort required to diagnose, treat, preserve or maintain an individual’s physical or emotional status.

Discharge Planning – The process of assessing the patient’s needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting including appropriate use of resources necessary for ongoing care.

Disease Management – A system of coordinated healthcare interventions and communications for populations with chronic conditions in which patient self-care efforts are significant. It supports the physician or practitioner/patient relationship. The disease management plan of care emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

Social Work – the social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilizing theories of human behavior and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.

Subacute Care Facility – A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services.

Telephonic Case Management – The delivery of healthcare services to patients and/or families or caregivers over the telephone or through correspondence, fax, e-mail, or other forms of electronic transfer. An example is telephone triage.

Workers’ Compensation – An insurance program that provides medical benefits and replacement of lost wages for persons suffering from injury or illness that is caused by or occurred in the workplace. It is an insurance system for industrial and work injury, regulated primarily among the separate states, but regulated in certain specified occupations by the federal government.

Precertification – The process of obtaining and documenting advanced approval from the health plan by the provider before delivering the medical services needed. This is required when services are of a nonemergent nature.

Utilization Management – Review of services to ensure that they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.

Utilization Review – A mechanism used by some insurers and employers to evaluate healthcare on basis of appropriateness, necessity, and quality.

Advocacy – Acting on behalf of those who are not able to speak for or represent themselves. It is also defending others and acting in their best interest. A person or group involved in such activities is called an advocate.

Durable Medical Equipment (DME) – Equipment needed by patients for self-care. Usually it must withstand repeated use, is used for a medical purpose, and is appropriate for use in the home setting.