Five ways case managers support better member outcomes

2. Managing benefits and resources

Case managers who work for a health insurance company have an extra opportunity to support members by helping them navigate policy benefits and payer resources. Within their daily workflow, they have insight into member care patterns and can help educate them so they get the most out of their care appointments with clinicians, such as asking key questions. They can also help develop personalized care plans that align with the member's needs and their insurance coverage, including additional covered services.

Additionally, having a case manager from a health insurance company helping members navigate the complex healthcare landscape can help improve member relationships and build long-term trust.

3. Reducing hospital readmission rates

Across the healthcare ecosystem, reducing hospital readmission rates is a shared goal, impacting clinician bandwidth, health outcomes, and overall costs. A 2021 report from the Keiser Family Foundation notes that approximately 5% of people with high healthcare costs—an average of $71,100 annually—accounted for just over half of total health spending. Many of these patients live with chronic conditions that require regular care.

Case managers can play an important role in reducing hospital readmission rates. A study was conducted on the impact of integrated case management versus standard treatment among patients diagnosed with diabetes and heart failure. From the case management group, 18.4% were readmitted within 30 days compared to 52.6% of the standard group. When case managers are connected to members who are at high risk for readmissions, it can help mitigate repeat visits by supporting care plans and addressing chronic conditions more consistently.

4. Providing member education and resources

Health educational content, directly integrated into case managers’ workflow and technology platforms, can be a valuable resource for them when working with and educating members, especially those with chronic diseases. Providing accessible, evidence-based educational content that’s aligned with clinician recommendations is an opportunity to supplement conversations at the point of care. Additionally, a 2022 Wolters Kluwer survey revealed that 80% of patients had follow-up questions after a health encounter, with non-White ethnicities being more likely to desire more information. Case managers have an opportunity to fill this information gap and support members with their next steps through content integrated directly into their day-to-day workflow.

Resources from case managers can include:

• Information on preventative measures and healthy lifestyles
• Explanations of medical terminology in accessible, everyday language
• Answering follow-up questions from clinical sessions
• Conducting workshops and webinars on topics
• Guidance for where to find resources and next steps, such as portals or specialists