Clinical Case Manager

Date of Publication:

4/9/2013

Definition:

A clinical case manager uses a collaborative process under the population health continuum to assess, plan, implement, coordinate, monitor, and evaluate options and services to meet an individual’s health needs through communication and available resources to promote quality, cost effective outcomes. The Managed Care Support Contractors (MCSC) clinical case manager delivers CM to TRICARE beneficiaries in the region where they reside who meet the case management (CM) criteria outlined by the regional MCSC, receive the majority of their healthcare in the purchased care system (PCS) system, and accept the offered services. The military treatment facilities (MTF) clinical case manager delivers CM to TRICARE Prime enrolled beneficiaries who meet the criteria outlined in this document and by the Services or Joint Medical Commands, receive the majority of their healthcare in the Direct Care System (DCS), and accept the offered services. The VA Operation ENDURING FREEDOM/Operation IRAQI FREEDOM/Operation NEW DAWN (OEF/OIF/OND) case manager (Master’s prepared RN or SW) provides CM services to eligible OEF/OIF/OND veterans at Veterans Affairs (VA) healthcare facilities. Wounded, ill, and injured (WII) OEF/OIF/OND Service members and veterans with poly-trauma, spinal cord injury, blindness or traumatic brain injury diagnoses may have a specialty care case manager. Specialty care case managers have unique expertise in treating and case managing patients in a specific specialty care area. The VA developed the concept of a VA lead case manager who assumes responsibility for coordinating care, communicating with the healthcare team, and serves as a central communication point for the veteran and his or her family. Non-OEF/OIF/OND Service member or veterans needing CM services are provided by social workers (SW) or registered nurses (RNs) in primary care or specialty areas.