1. Ongoing review of cases by clinical professionals to ensure the necessity of the clinical services given and most appropriate use of services to a patient. Typically, case managers are nurses or social workers. They may operate privately or may be employed by social service agencies or public programs. 2. Process that integrates and coordinates patient care in complex and high-cost cases. Sometimes a patient is referred to as case managed. 3. Process of developing a defined health care plan for a patient for better communication and to improve quality of care and reduce costs. Case management is sometimes a “carve out.” See carve out. 4. In the Medicare program, an arrangement of services needed to give proper health care to a beneficiary; tracking of beneficiary’s use of facilities and resources. Also known as catastrophic case management, catastrophic claim management, large claim management, or medical case management.
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Case management is used to manage healthcare costs in workers compensation. The case manager works with the insured, the physician, and the employer to design the most cost-efficient treatment plan. Case managers also monitor the injured worker’s progress and keep the employer and insurance company informed about the worker’s ability to return to work.