Nursing Specialization – Case Management

Case Management Nursing

There are three main responsibilities that individuals in the case management nursing field are charged with. They review the way hospital services are utilized, they plan patient discharges and they even ensure high-quality service throughout the facility. They also work to come up with long-term care plans for individuals with chronic or terminal illnesses.

Utilization of Hospital Services

An individual in this specialized nursing field will stay in close contact with patients, physicians, hospital administration and insurance companies to review the ways in which services are delivered.

These individuals may spend countless hours poring over patient charts and comparing information to ensure that these patients are getting the best care available to them.

They may also work with insurance companies to provide information about treatments that are deemed ‘medically necessary’ for the patient; this is sometimes necessary before health insurance companies to pay for certain treatments, surgeries or medications.

Quality Control

While there are usually separate teams responsible for quality control in large hospitals and facilities, smaller locations will often charge their case management specialists with this task. In general, this individual will oversee the quality of care that patients receive. Nursing interventions are, of course, part of the daily routine of case management nurses.

However, in some cases, this role may take on a legal aspect. Individuals in the field may be required to act as liaisons between hospitals, insurance companies and patients whenever disputes arise. This individual is typically a patient advocate in this case and works to ensure that the patient’s needs are met.

Planning Patient Discharge

An individual with a degree in this specialized nursing field may also be called upon to plan patient discharge—the term used when a patient is released from a hospital or other healthcare facility. Case management nurses may also be called upon to admit patients into the hospital.

In order to plan a patient’s discharge, the nurse will review the patient’s chart and insurance coverage as well as review the patient’s past medical history. When interventions are required, she will take care of that. All of this information will be used together to provide a viable discharge plan that corresponds with the physician’s orders.

These nurses will explain how to use any medications or equipment, when to return to the doctor, and when to seek emergency medical help after discharge.

Coordinating Long-Term Care

Patients who suffer from long-term, chronic or terminal illnesses also require the assistance of individuals with degrees in nursing with a specialty in case management. Many RNs who work in hospital settings are often confronted with questions like “are you new here, RN” but those working in nursing case management are not likely to get into this sort of embarrassing situations.

In such situations, these nurses review the patient’s illness, their past medical history, and their insurance coverage in order to come up with a healthcare plan that is designed to keep the patient as healthy as possible and out of the hospital. In this branch of the industry, nurses work with small groups of patients so that they may focus on each patient’s individual needs.

Some of the different groups include pediatric patients, geriatric patients, those with HIV or AIDS (though this is pretty well controllable today), and individuals who have various types of cancers.

Individuals who work in case management nursing will have an opportunity to truly get to know each of their patients. This allows them the opportunity to provide the best patient care possible in any number of settings, whether they work in hospitals, nursing homes or rehabilitation centers.