CCM Resource Management & Utilization 2

Question 1

A case manager identifies that a patient is repeatedly using the emergency department for non-urgent issues. What is the MOST appropriate first step in resource utilization management?

Accepted Answer

Conduct a root cause analysis to identify barriers to primary care access

Answer

Root cause analysis identifies underlying barriers such as lack of transportation or after-hours primary care access that drive inappropriate ED utilization.

Question 2

Which utilization review type occurs BEFORE services are provided to determine medical necessity?

Accepted Answer

Prospective review (prior authorization)

Answer

Prospective review, also known as prior authorization, evaluates medical necessity before services are rendered to ensure appropriate resource use.

Question 3

A case manager is coordinating care for a patient requiring durable medical equipment (DME). Which criterion is MOST critical when selecting a DME provider?

Accepted Answer

Medicare/Medicaid certification and patient-specific equipment needs

Answer

DME providers must meet certification standards, and equipment must match the patient's clinical needs to ensure safe and covered care.

Question 4

What does the term 'level of care' refer to in case management resource utilization?

Accepted Answer

The intensity of services and setting appropriate to a patient's clinical needs

Answer

Level of care refers to the intensity and type of services — such as acute inpatient, skilled nursing, or home health — matched to the patient's clinical condition.

Question 5

A case manager is working with a managed care organization to reduce inpatient length of stay. Which strategy is MOST directly effective?

Accepted Answer

Early discharge planning beginning at admission

Answer

Initiating discharge planning at admission identifies post-acute needs early, reducing avoidable delays and excess inpatient days.

(CCM) Certified Care Management Professional Practice Test

(CCM) Certified Care Management Professional Practice Test

CCM Resource Management & Utilization 2