The Basics

CM 4 sets forth minimum qualifications for case managers.  All case managers must be licensed or certified in a healthcare discipline that, in the applicable jurisidictions, allows them to conduct an assessment independently within their scope of practice.  The case manager also must have 2 years' experience of direct clinical care to the consumer.

Finally, the case manager must have one of the following three qualifications, presented in the alternative: health-related bachelors' degree, or CM certification, or a license as an RN.

Management Tip

Make sure your P&P on case manager qualifications is up-to-date -- this standard has been modified since the previous version of the URAC Case Management standards.

Note that most states won't allow an LPN to do CM assessment, so this might be one example of practice outside the scope of licensure.  If you've got LPNs doing case management, check your state law on this issue.

URAC Accreditation Tips

Two of the three elements are mandator; one is weighted 4.

Documentation for desktop review is a combination of job descriptions, a P&P that incorporates the requirements of this standard (including the requirement that the case managers stay within the scope of their licenses), and a list of your case managers, along with the credentials for each that allow them to be case managers under this standard.

For the onsite review, the URAC reviewer not only will examine some of your case managers' personnel files for compliance with this standard, but also will want to see attestations from each case manager that they are practicing within the scope of their licensure.  The reviewer also will verify this standard through interviews of the case management supervisor and some of the case managers themselves.