Operational Excellence & Efficiency Flashcards
7 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Operational Excellence & Efficiency flashcards as text
In stratifying a population for care management, a 'rising risk' tier is characterized by members who:
Answer: Have moderate chronic conditions with recent increases in utilization signals
Rising risk members show early warning signs of worsening health through utilization trends, making them ideal candidates for preventive care management interventions.
A care management program wants to improve its social determinants of health (SDOH) screening completion rate. The MOST effective operational intervention is:
Answer: Integrating a standardized SDOH screening tool into the initial assessment workflow
Embedding SDOH screening into the standard assessment workflow ensures it happens consistently as part of the care manager's established process rather than as a separate step.
Which metric BEST evaluates whether a care management program is achieving equity across member subpopulations?
Answer: Stratified outcome data by race, ethnicity, and language
Stratifying outcomes by race, ethnicity, and language reveals disparities in program effectiveness and allows targeted operational adjustments to achieve health equity.
A care management organization is preparing for a URAC Health Utilization Management Accreditation survey. Which operational documentation is MOST critical?
Answer: Clinical criteria and review decision-making processes
URAC accreditation requires evidence-based clinical criteria and documented, transparent decision-making processes for utilization management determinations.
The 'triple aim' framework in healthcare, developed by IHI, focuses care management programs on simultaneously improving:
Answer: Population health, patient experience, and per capita cost
The IHI Triple Aim framework guides care management program design toward simultaneously improving population health outcomes, individual patient experience, and reducing per capita healthcare costs.
When a care manager identifies that a member's care plan goals are consistently unmet over three consecutive months, the MOST appropriate operational response is:
Answer: Conduct a comprehensive reassessment to identify barriers and revise the care plan
Consistently unmet goals signal that the care plan may not align with the member's actual barriers, capabilities, or priorities, requiring reassessment and collaborative revision.
In care management operations, 'utilization management' (UM) and 'case management' (CM) differ primarily in that:
Answer: UM evaluates medical necessity of services while CM coordinates comprehensive care across the continuum
UM determines whether specific services meet medical necessity criteria for coverage, while CM takes a holistic approach to coordinating all aspects of a member's care across settings and time.