Case Management Concepts and Principles 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 Case Management Concepts and Principles flashcards as text
A case manager functioning in a 'gatekeeper' role is primarily responsible for:
Answer: Controlling access to specialist and specialty services to manage appropriate utilization
In the gatekeeper role, the case manager controls referrals to specialty services, ensuring appropriate utilization and preventing unnecessary or duplicative care.
Which case management model is most commonly used in insurance and managed care settings, with a primary focus on utilization management?
Answer: Insurance/managed care utilization model
The insurance/managed care model emphasizes utilization management, ensuring that healthcare services are appropriate, necessary, and cost-effective within the client's benefit structure.
The concept of 'levels of care' in case management refers to:
Answer: A continuum of care settings ranging from most intensive to least intensive
Levels of care describe the continuum from most intensive settings (ICU, acute inpatient) to least intensive (outpatient, home health), guiding appropriate placement and transition decisions.
Case management 'outcomes' are best defined as:
Answer: Measurable results of case management interventions at the individual or population level
Outcomes in case management refer to measurable results of interventions, such as improved health status, functional ability, quality of life, or cost-effectiveness.
The element considered most essential to an effective case manager-client relationship is:
Answer: Trust, collaboration, and client-centered communication
A therapeutic relationship built on trust, collaboration, and client-centered communication is foundational to effective case management practice.
'Medical necessity' criteria in case management is used to:
Answer: Justify the clinical appropriateness and need for specific healthcare services or treatments
Medical necessity criteria establish whether a proposed service or treatment is clinically appropriate and required, justifying authorization and coverage by the payer.
According to CMSA Standards of Practice, case managers have a professional responsibility to:
Answer: Maintain competency through continuing education and professional development
CMSA Standards require case managers to maintain professional competency through ongoing education and development in order to best serve clients.