What Does a Case Manager Do and Why Does it Matter?

Those who work in claims have heard the term case manager thrown around in clinical, administrative, advocacy, and cost containment conversations. But what do they actually do?

The reality is: case managers sit at the center of complex claims, bringing structure and coordination to situations that would otherwise unravel. And as medical care, recovery timelines, and claims processes become more complicated, the role of case management has become essential.

What Is a Case Manager?

The Case Management Society of America (CMSA) defines a case manager as

a healthcare professional who supports and coordinates care for patients, families, and caregivers as they navigate health and recovery.

That definition is important because it highlights something claims teams see every day: a case manager doesn’t operate in a silo.

They work at the intersection of:

• Medical care: treatment plans, providers, recovery progress
• Claims administration: documentation, timelines, return-to-work alignment
• Logistics: transportation, home support, equipment, access to care
• Advocacy & education: setting expectations and guiding claimants
• Communication: keeping providers, adjusters, employers, and families aligned
• Care oversight: monitoring progress and adjusting plans when recovery stalls
• Risk & barrier management: identifying delays, complications, or social obstacles early

In fragmented situations, the case manager becomes the point of continuity. They’re the person making sure everyone is working from the same plan.

What Does a Case Manager Actually Do?

While responsibilities vary by setting, most case management work falls into five core functions:

1. Assessment

Case managers evaluate:

• Medical conditions and treatment plans
• Functional limitations
• Barriers to recovery (social, environmental, or logistical)

They help determine not just what care is happening, but whether it makes sense for the overall recovery path.

2. Care Coordination

Healthcare is rarely linear. They help:

• Align providers
• Prevent delays between appointments or services
• Reduce duplication or conflicting recommendations

Without coordination, even good care can become inefficient care.

3. Communication

Case managers often act as the bridge between:

• Claimants
• Providers
• Adjusters
• Employers
• Carriers

They clarify expectations, timelines, and medical updates so misunderstandings don’t turn into escalations.

4. Planning and Monitoring

Recovery plans change. Case managers:

• Track progress
• Identify when treatment isn’t moving things forward
• Help adjust plans when conditions evolve

This keeps claims from drifting without direction.

5. Advocacy and Education

They help claimants understand:

• What’s happening
• Why certain steps matter
• What comes next

When people understand the process, compliance improves and frustration drops.

For claims teams, all of this translates into fewer surprises, clearer documentation, and more informed decision-making.

Why Case Management Matters in Claims

A small percentage of complex, high-utilization cases often drives a disproportionate share of overall costs. These are the claims with:

• Multiple providers
• Comorbidities
• Delayed recovery
• Social or logistical barriers
• Communication breakdowns

Left unmanaged, they can lead to:

• Prolonged durations
• Unnecessary or duplicative treatment
• Escalating costs
• Frustrated claimants and stakeholders

Case management helps stabilize these cases by identifying issues early, aligning care, and keeping recovery plans realistic.

For adjusters and claims professionals, that support isn’t just clinical; it’s operational.

Why the Need for Case Managers Is Growing

The demand for case management is increasing because claims are getting more complex. Contributing factors include:

• An aging population
• Higher rates of chronic conditions
• Longer recovery timelines
• Fragmented healthcare systems

In this environment, coordination is no longer a “nice to have.” It’s the difference between a controlled claim and one that spirals.

Case managers help bring order to that complexity by keeping communication consistent and care plans grounded in practical realities.

Where The Case Manager Fits in the Claims Ecosystem

Case managers work across multiple claim types, including:

• Workers’ compensation
• Disability and absence management
• Auto and liability
• Health and managed care
• Catastrophic and long-term cases

Regardless of the setting, the goal stays the same: reduce friction, improve clarity, and support medically appropriate outcomes.

The Case Manager as a Translator and Guide

One of the most overlooked parts of the role is education.

For many claimants, case managers may be the only people who:

• Explain the process in plain language
• Set realistic expectations
• Connect medical decisions to the claims process

That clarity builds engagement, and engagement supports recovery.

In that way, case managers don’t just coordinate care; they help maintain trust in a process that can otherwise feel overwhelming.

Final Thoughts

A case manager is not just a coordinator or observer. They are an active facilitator in the most complex moments of a claim.

Effective case management helps:

• Improve outcomes
• Control costs
• Reduce friction
• Support better experiences for claimants and claims teams alike

As claims continue to grow more layered, the role of the case manager becomes more central to recovery, resolution, and long-term system efficiency.

Stronger coordination leads to stronger outcomes. Discover how effective case management supports recovery and claim resolution.