Resource Management & Utilization 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 Resource Management & Utilization flashcards as text
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?
Answer: Conduct a root cause analysis to identify barriers to primary care access
Root cause analysis identifies underlying barriers such as lack of transportation or after-hours primary care access that drive inappropriate ED utilization.
Which utilization review type occurs BEFORE services are provided to determine medical necessity?
Answer: Prospective review (prior authorization)
Prospective review, also known as prior authorization, evaluates medical necessity before services are rendered to ensure appropriate resource use.
A case manager is coordinating care for a patient requiring durable medical equipment (DME). Which criterion is MOST critical when selecting a DME provider?
Answer: Medicare/Medicaid certification and patient-specific equipment needs
DME providers must meet certification standards, and equipment must match the patient's clinical needs to ensure safe and covered care.
What does the term 'level of care' refer to in case management resource utilization?
Answer: The intensity of services and setting appropriate to a patient's clinical needs
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.
A case manager is working with a managed care organization to reduce inpatient length of stay. Which strategy is MOST directly effective?
Answer: Early discharge planning beginning at admission
Initiating discharge planning at admission identifies post-acute needs early, reducing avoidable delays and excess inpatient days.
Which of the following BEST describes interoperability in the context of healthcare resource management?
Answer: The ability of different health IT systems to exchange and use patient data
Interoperability enables seamless data exchange across health IT systems, reducing duplication of services and improving care coordination efficiency.
When a payer denies coverage for a requested service, what is the case manager's PRIMARY responsibility?
Answer: Inform the patient and assist in filing an appeal with supporting clinical documentation
Case managers must advocate for patients by ensuring they understand denial reasons and by supporting appeals with clinical evidence to overturn inappropriate denials.