When the man entered the hospital, his diabetes and his weight had spiraled so far out of control that his doctors feared he would not survive. Maria Ortiz, RN, CCM, a case manager for the insurance company Aetna’s North Central region, was assigned his case.
For an entire year, she helped coordinate his care and monitored his progress--from the hospital to a skilled nursing facility and finally back to his home. She spoke by phone so frequently with the man’s wife that they recognized each other’s voices from the first friendly hello. And although she never actually performed any of the patient’s hands-on care, Ortiz felt the joy of his recovery just as much as if she had been his bedside nurse.
Nurse case managers like Ortiz care for the most chronically and seriously ill and injured patients in the health care system. They work for a variety of employers, including hospitals, health insurance plans, HMOs, rehabilitation facilities, government agencies, workers compensation insurers and more. In addition, some nurse case managers strike out on their own as independent consultants, offering their services to patients’ families, insurance companies and health care providers.
Case managers assess, plan, coordinate and monitor services up and down the health care continuum to ensure that patients get the high-quality care they need in a prompt, cost-effective manner. The ultimate goals are a healthier population and more-affordable health care.
One of nurse case managers’ most critical functions is to educate patients, guiding them to follow dietary, exercise and medication recommendations. According to the American Heart Association, complications from patients’ failure to take prescribed medication as directed by doctors account for 125,000 deaths per year in the United States, a mortality rate exceeded only by heart disease, cancer and stroke.
No matter what setting they work in, the chief role of nurse case managers is that of patient advocate. Case managers who work for insurance companies, for instance, make sure members get the services to which they’re entitled under their benefit plans. They also help negotiate better rates for services that aren’t covered or help find community resources to fill the gaps. Yet many Americans continue to harbor the misconception that insurance company case managers are bean counters whose only concern is to save the company as much money as possible.
“I’ve never been asked to compromise a member’s care or well-being based on cost,” says Joyce Rogers-Granberry, RN, an African-American nurse who is a regional case management director for WellPoint Health Networks. “We focus on what’s going to bring the most value to the patient.”
Adds Ortiz, “Even though I work for the insurance company, I really work for the patients and do whatever is best for them. I’m the human being behind the insurance company.”
Case management is an advanced, specialty practice. Entry-level nurse case managers must be RNs, preferably with a bachelor’s degree in nursing, and have at least two years of nursing experience. That experience is essential because a case manager must have a working understanding of the health care system, according to the Case Management Society of America (CMSA), an 8,200-member professional association based in Little Rock, Arkansas.
Experience in utilization review and home health care is also helpful. In fact, some insurers require home health care experience because their nurse case managers coordinate care after the patients are discharged from hospitals or skilled nursing facilities.
According to a 2003 salary survey conducted by CMSA and ADVANCE for Providers of Post-Acute Care magazine, average annual earnings for case managers--including those in allied health or social service fields--range from $50,000 to $57,000, depending on location. Case managers in metropolitan areas earn the most, with a nationwide average salary of $53,833. The national average earnings for case managers in suburban areas and in rural areas are $50,000 and $49,666 respectively, the survey reports.
Best of all, demand for nurse case managers is fierce. “Employers tell us that finding qualified nurse case managers is one of the biggest challenges they’re facing right now,” explains Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA.
Most of the job opportunities are in managed care and hospital settings, Boling continues. Meanwhile, a growing number of nurse case managers are setting up their own practices.
Because cultural competency is a top priority in case management, there is a great need for more racial and ethnic minority nurses in this specialty. Bilingual nurses are in particular demand, especially in workers compensation, says Claudia Worth, RN, a principal of Compass Continuum, a nurse case manager staffing company serving the Denver metropolitan area. She is also a principal of RNCaseManager.com, an online resource for nurse case managers.
Ortiz agrees that there is a critical need for bilingual case managers who can translate information for patients who speak little or no English. Ethnic minority nurses also bring personal perspectives that enable them to coordinate care in a culturally sensitive way, she adds.
In some Hispanic cultures, for instance, doctors are viewed as supreme authorities, which makes patients reluctant to seek second opinions. Yet in other Hispanic cultures, doctors may be viewed with suspicion. Ortiz tells of one patient from the Dominican Republic whose beliefs in voodoo led him to distrust physicians. Understanding the nuances of different cultural subgroups helps nurse case managers communicate more sensitively with patients and their families, which can lead to better outcomes for the patients.
A nurse case manager’s job is never dull, and it requires strong organizational skills. Case managers carry average caseloads ranging from 22 in rehab facilities to 47 in managed care, medical group or workers compensation settings, according to CMSA and ADVANCE for Providers of Post-Acute Care. (Those figures, however, include caseloads for social workers and other types of case management professionals, not just nurse case managers.) Some case managers can even carry 60 or more cases at a time. New cases come in every day and case managers must prioritize.
Rogers-Granberry says a typical day for a case manager at WellPoint might begin with a phone call informing him or her that a health plan member has been in a serious car accident and suffered a spinal cord injury while on vacation. First, the case manager would coordinate getting the member to the closest hospital, where his condition could be stabilized. Then the case manager would coordinate his transfer to a hospital where he could be treated, all the while working closely with the member’s family and with doctors. If the patient needed a service that wasn’t covered by his health plan, such as an air ambulance, the case manager would work with service providers to negotiate the best rate possible. Once that crisis was under control, the case manager would take care of details of other cases that required attention that day.
In some instances, a patient can have more than one case manager--perhaps one working for a hospital and another working for his health insurance plan. The two case managers then work together to coordinate care. As Ortiz puts it, “We help them and they help us.”
As a case manager for mental health emergency services at Jackson Memorial Hospital in Miami, Ruby Murphy, RN, MS, juggles the cases of 20 to 25 patients who are already in the hospital, plus up to 40 patients who come into the emergency room each day. “You really have to start organizing your day in the car on your way here,” says Murphy, who is African American.
She communicates by phone, email, walkie-talkie or fax with nurses, doctors, social workers and other hospital staff, as well as family members and representatives of community agencies and insurance companies. She also does walking rounds to review charts and talk to hospital staff face-to-face when necessary. Her goal is to gather and share information as fast as possible so patients get the care they need.
Obviously, good communication skills are critical. Murphy says case managers must be able to establish rapport with a wide range of people--from hospital housekeeping staff to surgeons to insurance administrators.
In a mental health setting, case managers must have both general medical knowledge and psychiatric knowledge in order to assess patients, she adds. For example, sometimes it’s necessary to transfer a patient from the mental health unit to the general emergency department.
Case managers also must be resourceful, because they often have to find ways to fill the gaps in a patient’s care. That could mean helping patients get transportation to a pharmacy or helping them get enrolled in a government insurance plan, such as Medicaid.
Case management isn’t for everybody. The job involves working in an office, rather than at bedside, and the case manager’s primary tools are the computer, telephone and fax machine. This career also requires a broad perspective of the health care field.
“For some nurses, it’s very hard to make the transition to the managed care area,” says Lisa Harris, BSN, RN, CCM, a case management supervisor for WellPoint in Atlanta. “You have to look at the business aspects of health care in conjunction with the clinical side.”
This means case managers take into account considerations such as benefits, eligibility, contractual and legislative issues, as well as medical and clinical practices, in order to make medical necessity determinations. All of these components are critical for making sure patients are treated consistently according to the current standards of practice.
On the other hand, if you’re a long-time bedside nurse who feels it’s time to explore new career possibilities, case management may be just what you’re looking for.
After beginning her career in clinical nursing, Harris, who is African American, got the opportunity to work in a utilization management department at a peer review organization. She later transitioned into quality improvement and then into case management. She has worked in managed care on the hospital side as well as for a variety of national health plans. In her current supervisory role, she leads a comprehensive case management team and is the interim supervisor for the East Coast transplant case management team.
“I love to learn new things and seek out new challenges,” Harris declares. “Case management encompasses the best of both worlds. As a case manager, you assist members not only while they’re in the hospital or in the acute phase of their illness, but you also have the opportunity to follow their care through a continuum.”
She likes being part of the whole spectrum of care and getting the satisfaction of seeing plan members enjoy optimum results at the end of the process. She especially cherishes the notes and photos her team receives from grateful parents whose babies are thriving despite having been born prematurely. Harris can’t help but take delight in the photos of them now as toddlers, smiling and walking and bringing joy to their families.
Every case manager recalls special cases that touched their hearts. Murphy remembers the case of an elderly woman with dementia who got on the wrong bus and ended up in Miami, not knowing who or where she was. Murphy coordinated the search for the woman’s family and her care while she was at the hospital. After an APB was issued, the frantic family contacted the hospital from their home in New York and flew to Florida to pick her up. “They were very gracious and were just so happy to see their mom,” Murphy says.
Such happy endings are the great rewards of case management careers, she adds.
“I find that assisting people at this level is just as vital as stopping the bleeding at the bedside.”
Ortiz became a case manager after working as a nurse for 30 years, first in general nursing at hospitals and then in home health care. She figured she wouldn’t have the physical stamina to do hands-on care for the rest of her career and she was ready for new challenges. She seized an opportunity to be a case manager at Aetna, and now, she says, “I don’t think I’ll ever go back to anything else.”
The Case Management Society of America, www.cmsa.org, offers educational programs, an annual conference, interactive networking forums, leadership training, publications and an online career center with listings of current job openings and a resume database.
The Association of Rehabilitation Nurses, www.rehabnurse.org, has a case management Special Interest Group.
RNCaseManager.com provides job and resume postings, an online case manager forum, online continuing education courses and links to resources for case managers.
The International Association of Rehabilitation Professionals, www.rehabpro.org, has a case management section on its Web site.
What Makes a Good Case Manager?
According to the Case Management Society of America, these are some of the key skills and qualities necessary for a successful career as a case manager:
• Problem solver
• Out-of-the-box thinker
• Sense of humor