The role of a case manager in a hospital

A hospital case manager is a professional who handles the hospital's discharge planning and utilisation reviews. The case manager is usually a registered nurse, but anyone with the right experience can be a case manager. They often collaborate with social workers, physicians, nurses and other medical staff to provide important medical care to patients.

A case manager's responsibilities include working with your doctor and the team providing services to you in:

Creating discharge plans for patients

Discharge plans help case managers to determine if the patient will need further help or care after they leave the hospital. The case manager will communicate with the patient or their family about the steps to take to help them recover after they're discharged. This may include follow-up hospital visits or getting home based care.

Completing utilisation reviews

Utilisation reviews help to make sure that hospitals follow important protocols and that patients receive the highest care for their conditions or illnesses. These reviews help manage the cost of healthcare benefits by assessing and deciding the appropriate treatment for a patient's condition before treatment is provided, using evidence based criteria or guidelines.

Compiling information for the patient's medical scheme

Case managers compile the necessary information to give to the Fund. This can include the patient's current medical condition, information about their medical history and any information that is relevant to their hospital visit. This helps the case manager to get a better understanding of the patient's condition, help them negotiate with the Fund and do their best to prevent claim denials.

Creating rehabilitation plans

If a patient needs rehabilitation after being discharged, the case manager will communicate with the patient, their family, and the Fund to create a suitable plan. The case manager will usually try to find a rehabilitation programme or specialist that provides the best care and is covered by the Fund.

Negotiating cover benefits

If a patient needs specific treatment for their condition that the Fund doesn't cover, the case manager might arrange a meeting with the patient, the Fund and other medical professionals. Together they'll try to find a suitable solution. For example, the case manager might consult with doctors and pharmacists to see if there are other options or possible payment plans available.

In some of the large hospitals across the Country, you may meet a Discovery Health case manager when you are in hospital. The case manager is a member of the team looking after you when you are in hospital and focuses on ensuring you are receiving the right level of care and makes it easy for you to obtain the necessary authorisations from the Fund.