In theory, case management is a health care delivery process whose goal is to decrease fragmentation, enhance the patient's quality of life, and contain costs. The nurse case manager oversees these critical paths and facilitates interventions to ensure that the patient progresses through the desired events appropriately and satisfactorily. In some managed care organizations, a case manager addresses the long-term needs of the enrolled members, not just their current interaction within the system. Responsibilities may range from identifying the provision of needed care to educating patients on health promotion and disease prevention activities, as well as informing them about the benefits the health plan covers and how to use the system effectively. Nurses act as professional advocates for the patients who may not be fully knowledgeable regarding the system or the benefit plan.
Nurses also act as advocates to assist patients in the appeal process.
An important function in managed care organizations is ensuring that patients receive timely access to the appropriate level of health care services. A strategy often employed to direct patients through the system is to use a triage nurse to handle telephone calls and on-site visits from patients who present with sudden problems. In a managed care organization, the triage nurse listens to the patient describe the problems and symptoms, reviews the patient's medical record, decides which course of intervention is most appropriate, and advises the patient accordingly. This mechanism for directed access to health care services achieves more efficient and effective utilization of the health care delivery system. A function that is tied closely to quality improvement and utilization management is risk management, which involves decreasing the probability of incurring adverse outcomes.