Case Management
Understanding what is important in the role of case management.
When it comes to case management there are three important considerations:
- What gave rise to the condition, and to what extent can these contributory factors be mitigated,
- has the diagnosis been confirmed and what if any are coexisting conditions,
- thirdly the severity of the conditions and are all the diagnosed conditions being optimally treated, and what precautions need to be taken to prevent further complications or adverse clinical events?
Case Management Clinical Audits
Clinical audits in case management.
Clinical audit of case management is sensible because it provides objective assurance that care decisions are clinically appropriate, evidence-based, and aligned with agreed protocols and benefit rules. By systematically reviewing cases, audits identify gaps in assessment, documentation, coding accuracy, and care coordination, as well as unwarranted variation in practice.
Coding in Case Management
Coding in case management.
Coding is fundamental to effective case management because it translates clinical reality into a structured, comparable language that drives decision-making, funding, and outcomes measurement. Accurate diagnostic and procedure coding ensures that a member's condition, severity, and co-morbidities are correctly understood, enabling appropriate care pathways, benefit allocation, and referrals. It supports continuity of care across providers, allows meaningful data analysis for risk stratification and population health management, and underpins fair reimbursement and claims integrity. In short, good coding is the backbone that links clinical care, cost control, and quality outcomes in case management.