Case management is an approach to managing the provision of healthcare to members with high-cost medical conditions. The goal is to coordinate the care to improve both continuity and quality of care and to lower costs.
This generally is a dedicated function in the utilization management department. The official definition, according to the Certification of Insurance Rehabilitation Specialists Commission, is as follows: “Case management is a collaborative process which assess, plan, implements, coordinate, monitors, and evaluates the options and services required to met an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes” and “occurs across a continuum of care, addressing ongoing individuals needs” rather than being restricted to a single practice setting.
When focused solely on high-cost inpatient cases, it may be referred to as large case management or catastrophic case management. Gillian I. Russell, Terminology, in FUNDAMENTALS OF HEALTH LAW 1, 5 (American Health Lawyers Association 5th ed., 2011).