What is case management?

Growing organizations will always benefit from workflow and process automation to streamline repetitive tasks. These tasks include day-to-day business activities such as document routing, invoice approval and data entry.

But what happens when the steps needed to complete a business process demand flexibility? Dynamic decisions need to be made, for example, when insurance firms must evaluate whether a patient’s medical claim can be approved, human resources (HR) departments must solve an employee dispute and other non-routine tasks that require human intervention.

For instances like this, organizations will need to deploy efficiency-driven case management strategies to support their decision-makers and case managers.

What does case management mean?

Case management is a procedure for managing data relationships, documents and processes for unique cases, like service requests, investigations or incidents that require action and resolution.

This encompasses the recording, monitoring and analysis involved in processing the data, procedures and related content that comprise a case.

Unlike business process management (BPM), which focuses specifically on workflows and repeatable processes, case management is a more holistic technique for managing work and processes that are not repeatable. Case management solutions are designed to improve knowledge-driven work as well as improve general processes to optimize outcomes.

> Learn more | How does BPM differ from RPA?

Some business activities that a case management solution can improve are:

• Project management
• Compliance tracking
• Vendor management
• Contract management
• HR onboarding
• Incident resolution
• Fraud investigation

What is a case manager?

A case manager coordinates the entire process an incident, event, request and investigation must go through to reach its objective or resolution. They are responsible for assessing, planning, implementing, evaluating and reporting on a specific case from start to finish.

The duties of a case manager include:

• Assessing the risk levels of a specific event, customer or employee before registering it as a case
• Creating a tailored plan based on the desired outcome
• Involving other business professionals and specialists in a workflow for added guidance, or connecting individuals with external service providers
• Monitoring and tracking timelines, milestones and overall status updates of a case
• Evaluating the outcome of a case and producing reports for the business

What are the different models of case management?

There are four main case management models to consider based on your organization’s unique requirements. Each has a different focus, which can be either modified or combined to reach a specific business outcome.

Brokerage

In the brokerage model, case managers connect services provided by various businesses and professionals to their customers. This usually involves extending support and other resources to customers in an office-based setting.

With a brokerage model, case managers are much less involved with the people they serve on an individual level. They place less emphasis on continuous monitoring and more focus on data collection and reporting across service providers. In turn, this allows them to allocate their attention to many cases at a time.

Intensive case management (ICM)

An intensive case management (ICM) framework is reserved for individuals or incidents that require critical and ongoing support.

Organizations that deploy an ICM model require case managers to be consistently engaged and updated on case progress. Here, case managers must extend resources to their customers through routine evaluations, appointment follow-ups and other personalized rehabilitation services if needed.

Clinical case management

Clinical case management involves certified therapists or counselors assigned by clinical providers. This type of case management model is commonly reserved for organizations that offer clinical therapy, addiction recovery and crisis intervention services.

Case managers in this model work directly with their customers in an office-based atmosphere to curate specific treatment plans. Clinical case management is highly personalized and involves detailed recordkeeping, allowing case managers to quickly identify gaps in treatment and deliver required services with greater efficiency.

Strengths-based clinical case management

The strengths-based clinical case management model focuses on the strengths of involved individuals before developing a treatment plan. It starts by identifying their desired outcomes and personal objectives — following up with a care plan matching their unique background to a personalized route to treatment.

For case managers, this model heavily focuses on critical evaluation and reporting. The dynamic nature of a strengths-based clinical case management approach requires case managers to be supported by real-time solutions that can track a customer’s crucial documents and status updates regarding their case.

The core tasks of case management

Every case management workflow consists of crucial steps to address a problem and deliver the highest standards of service. Case managers are responsible for six essential tasks as part of this process.

1. Screening

Every case management process starts with identifying whether the issue in question requires a higher degree of problem-solving and attention to detail. In the screening phase, case managers must determine if a case cannot be quickly resolved.

For example, if service requests require more actionable information, if customers need greater technical support or an incident requires further investigation.

2. Assessing

In the assessment phase, case managers will start by gathering basic information about a potential customer (medical records, current financial status, etc.) or a specific incident.

In this situation, case management software is used as a single source of truth for all case managers to view and manage relevant documents in the form of personal assessments, background checks, incident reports and other collected data to move the process along.

3. Evaluating risks

Before a solution can be proposed, an organization must understand the severity of a case. Cases can be divided into three categories: low-risk, moderate-risk and high-risk situations.

In a medical setting, patients are classified according to their risk types based on pre-existing medical conditions and the urgency of care needed. For higher education institutions, the most at-risk students are categorized based on low retention indicators or poor academic performance.

4. Planning

The planning stage turns collected incident reports, background information and all forms of gathered data into an actionable plan. Here, case managers are required to outline a step-by-step proposal to address desired objectives along with methods of execution.

Having an initial strategy in place helps case managers understand risks that may arise in a plan, identify the best ways to be in compliance and seek guidance from other professionals if necessary.

5. Implementing

Case managers can move forward to the implementation and execution phase once a solid plan is finalized.

Legal departments, for example, might require case managers to launch negotiation talks, start settlement processes or continue to a trial with the parties involved in a case. HR departments could assign a specific case manager to multiple new hires at a time, ensuring that all employees have access to their training materials, business laptops, access cards and other resources to get started with a new position.

6. Following up

How do organizations and case managers subsequently determine the efficacy of a plan? The follow-up phase monitors if all implemented solutions, services and processes can successfully resolve a problem or reach a specific business objective.

If the desired outcome cannot be achieved according to the timeline or in line with expectations, case managers are able to intervene and suggest a new course of action or work to optimize the case management strategy.

7. Evaluating

The final step of the case management process is the data collection and reporting phase. The evaluation stage considers metrics like customer satisfaction, objectives reached, overall costs, case duration, ROI for your organization and other results that can determine how well a process was carried out.

Organizations are then able to compound these detailed case records in one place and continue to make continuous improvements to case management efficiency in the future.

Examples of case management

In an organization’s daily activities, many scenarios may need the attention of case management. These include:

Service request management

Service requests can be made by users in an organization or by customers themselves to improve and maintain a business’ products, services and other assets.

This workflow starts out with submission of a request through a portal or via other forms of communication utilized by an organization. Requests are categorized based on priority and then assigned to a case manager or agent for further actions, reviews and approvals. The lead case manager will then follow up with the party who requested the service to understand if the desired objective has been reached.

Implementing case management software with prebuilt workflow automation features means that this entire process goes on with minimal operational bottlenecks. Case managers and all other professionals involved in a case can track and manage multiple requests at once, exchange critical information faster and be notified of deadlines or pending actions.

Claims processing

Claims processing refers to validating and confirming the information in a claim before it is approved for settlement.

A streamlined claims processing workflow starts with an initial claim filing to relevant departments. This is followed by a thorough vetting process of the claim based on its authenticity, documents or information provided and individual coverage. Case managers then make a calculated decision to approve or reject the claim based on available criteria.

Organizations that receive multiple claim requests daily must ensure that no fraudulent claims are overlooked, all compliance standards are followed and no inconsistent or ad-hoc processes are implemented. Automated claims processing through case management software allows case managers to expedite reviews, approvals and rejections by:

• Following up on task-related actions with automated notifications
• Distributing work to other professionals based on authority levels and user permissions
• Accessing all vital case information pertaining to a claim from one platform

Read more: The Forrester Wave™: Digital Process Automation Software, Q4 2023 report

Incident management

Incident management refers to the reporting, investigation and resolution of an issue. Here, case management efforts work towards the ultimate goal of resolving a problem with minimal negative impact on the best interests of all parties affected.

Managing and resolving an incident that involves multiple teams, employees or other parties requires maximum transparency. Following that, management must have the full picture before carrying out any sort of decision.

Case management software clearly outlines workflows, user roles, business tasks and status updates to what is clearly a time-sensitive and mission-critical process.

> Read more | How an electronic document management system (EDMS) facilitates greater control over case management processes

Case management across functions

Case management strategies will look different depending on the nature of incidents, requests, claims, approvals or other events that come into an organization daily. These are four common industry-relevant ways a case management process can be applied. This removes the guesswork when it comes to maintaining compliance and allows management to deploy better procedures to prevent similar issues from happening again.

Medical case management

Medical case management connects tailored or general treatment plans to patients with disabilities, injuries and other illnesses to ensure that they receive the highest standard of care.

Workflows in a medical case management process would look like:

• Having an in-depth interview or assessment with a patient
• Designating a case manager to the specific patient
• Including doctors, nurses, specialists or other health practitioners to curate a treatment plan
• Gathering information and following up post-treatment to report on the outcomes of the administered care plan
• Fulfilling release of information requests in a timely manner

Legal case management (LCM)

Legal case management (LCM) details the variety of strategies, tools, and techniques that law firms, judges, law associates and courts employ to manage the life cycle of a case better.

The primary feature that makes case management software beneficial to a law firm is its capability to organize and store case-specific data on a single platform. Case management solutions would also allow for the secure management and sharing of contracts with witnesses, lawyers, experts and other parties involved in a case.

Insurance case management

Insurance case management processes highlight how case managers track, evaluate, review, approve or reject claims made by their customers or employees.

Case managers in this function would generally go through a workflow of assessing the risk profiles of a customer, investigating the claim based on policies and arranging for payment to be made if all criteria are matched. Digitizing the paper trail — especially for property and casualty or life and annuity companies that involve document-heavy processes — allows insurers to search for relevant information much quicker and have all the data on hand to keep them from approving fraudulent claims. 

> Learn more | How federated search consolidates information from various data sources 

HR case management

HR departments are responsible for managing massive amounts of documents, processes and people daily. Ad-hoc workflows would leave teams overwhelmed with switching back and forth between email inboxes, personal hard drives or paper copies to stay on track with their case development.

A HR case management solution would mean more robust mechanisms to handle daily employee events, inquiries, requests and incidents. This solution would streamline:

• Onboarding new employees: Sharing training materials, electronically signing documents and assigning case managers to oversee new hires.
• Handling employee complaints: Addressing employee grievances, safety violations or other forms of misconduct.
• Centralizing employee file management: HR professionals do not need to juggle between multiple platforms and instead securely collaborate, sign and share employee files with users internally and externally.

Why should case managers use case management solutions?

Case management software allows your case managers to effectively manage customer relationships, documents and processes on a single platform. This solution streamlines claim submission, complaint management, contract collaboration and other activities that require a combination of automated workflows and manual intervention.

Case managers can improve the quality of their work and customer satisfaction through a case management solution. The right provider will:

• Increase productivity and ensure continuity with a complete view of information. Rather than having to toggle between systems or manage spreadsheets, staff remain within the same intuitive interface, logging activities, adding notes and updates, delegating tasks, and scheduling events.
• Improve visibility and control. Reporting dashboards and audit trails of all activities increase transparency, support compliance and help organizations identify opportunities for improvement.
• Ensure smooth handoffs and effective collaboration. Organizations can support effective collaboration by having critical information and supporting content instantly accessible to all authorized employees throughout a case.