The Case Management Process in Health Insurance Triage
by Holly Orth Kelley, RN, CCM
I am a certified case manager and work as a triage nurse for a large health insurance company. While it is the common conception that case management is applied individually to people with chronic illness or disability, I apply the case management process in my position as a triage nurse. It is my responsibility to identify new members who would benefit from case management. Every new member answers a Health Risk Assessment in accordance with Medicare guidelines. I “triage” the questionnaires to identify any case management needs. Application of the case management process from assessment through outcomes has streamlined my workflow tremendously. The process keeps me on schedule with approximately 1,000 new members monthly.
In order to triage, I start with an assessment. This is done by evaluating the questionnaire the member answered. Through assessment of specific questions and their answers on paper, I am able to determine if a member requires a telephone assessment. The telephone assessment affords me the opportunity to ask in-depth questions and determine level of need. The result of the assessment may indicate the need for immediate case management, or that a new member needs to be assigned to a case manager for long-term needs.
The case management process is very helpful when I identify immediate needs. A new member may need a glucometer and testing supplies to monitor their diabetes. I plan for the equipment and coordinate delivery and set-up. A follow-up call is made to monitor the implementation of my plan and to evaluate effectiveness. Throughout this process, I document outcomes; and when goals have been met, I close the case.
Oftentimes my phone call will identify the need for a case manager to be assigned to a new member for long-term needs. This may be for a specific diagnosis that requires intervention, problems with a doctor or issues around obtaining or taking medications properly. We see a lot of social issues that need to be addressed with our population as well. After assessing for and identifying the need for case management, I plan for assignment to a case manager and coordinate that referral. I am able to monitor case manager involvement, implementation of care plans and evaluation of outcomes through the use of computer software.
In general, my triage duties are tracked for trends in case manager assignment and follow-through. We are able to track disease conditions requiring the greatest level of case management as well as social issues at the forefront of our population’s needs. The triage position has allowed the insurance company to capture the sickest of the sick and address their needs before they are hospitalized or institutionalized. Through early identification using the case management process, we become proactive in identifying our members’ needs and addressing them. Thus we keep our population as healthy as possible through access to the appropriate level of care and services at a reasonable cost to the member and the company.
