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Nurse Case Manager Test Questions With Accurate Answers, Exams of Nursing

Nurse Case Manager Test Questions With Accurate Answers

Typology: Exams

2024/2025

Available from 07/03/2025

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Nurse Case Manager Test Questions
With Accurate Answers
(TPA) Third party administrator correct answer Organization that
processes health claims and other business related functions of health
plan
3 types of measurements of performance improvement correct answer
1) process
2) structure
3) outcome
4 components of interpersonal communication correct answer sender
message
receiver
context
5 basis ethical principles correct answer Beneficence
Non-malfeasance
autonomy
justice
fidelity
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
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Nurse Case Manager Test Questions

With Accurate Answers

(TPA) Third party administrator correct answer Organization that processes health claims and other business related functions of health plan 3 types of measurements of performance improvement correct answer

  1. process
  2. structure
  3. outcome 4 components of interpersonal communication correct answer sender message receiver context 5 basis ethical principles correct answer Beneficence Non-malfeasance autonomy justice fidelity

5 stages of change correct answer 1. Precontemplation

  1. Contemplation
  2. Preparation
  3. Action
  4. Maintenance Accreditation correct answer entails voluntary survey process that assesses the extent of a healthcare organization's compliance with the standards to improve patient outcomes ADA - American Disabilities Act defines a disability correct answer 1) has a physical or mental impairment that limits a major life activity
  1. has a record or history of a substantially limiting impairment
  2. is regarded by ER as having a substantially limiting impairment
  3. also protects prior drug addiction if they have been rehab'd. Beneficence correct answer to do good CAGE tool correct answer cut down, annoyed, guilty, eye opener Capitation correct answer A fixed amount of money per-member-per- month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method

COB - Coordination of Benefits correct answer a program for determining which health insurer pays for services first when a beneficiary is covered by more than one health care plan. Primary or secondary insuracne Concurrent review correct answer review for medical necessity of tests and procedures ordered during an inpatient hospitalization. Another form of UR that tracks consumption of resources while IE is hospitalized Conflict resolution strategies correct answer 1)collaboration

  1. negotiation
  2. accommodation
  3. competitive
  4. avoidance continued stay review correct answer used to determine that each day of the hospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a patient's hospitalization for care. Custodial Care correct answer Care provided primarily to assist a patient in meeting the activities of daily living but not requiring skilled nursing care.

Diagnosis correct answer System that categorizes into payment groups patients who are medically related with respect to diagnosis and treatment and statistically similar with regard to length of stay. Used by Centers for Medicare/Medicaid services (CMS) to pay hospitals. Dual Diagno correct answer the client with both substance abuse and another psychiatric illness Examples of hard savings: correct answer transfer to a lower level of care decrease in length of stay negotiation to a lower rate for a service change to an in-network provider Examples of soft savings: correct answer avoided hospital readmission prevention of medical complications avoided ER visits. Exclusive Provider Organization correct answer managed care plan that provides benefits only if care is rendered by providers w/in a specific network Fee fo correct answer Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.

Inpatient Rehab correct answer Pt's must be able to tolerate 3hrs/day of therapy, 5-7 days/wk, and be medically stable. LTD- Long correct answer Portion of wage replaced waiting period (usually after STD ends) Covers non-work related injury/accident/illness premium paid by ER/IE/both ends at 65 Medicare HHC part A correct answer -Covers first 100 days following a 3 day hospitalization of SNF

  • no copay/deductible
  • HHA
  • full time nursing NOT covered Medicare IP coverage part A correct answer starts first day and ends when there has been a break of at least 60 days since the IP or SNF
  • no limit to the nuber of benefit periods covered during a beneficiary's lifetime
  • IP is normally limited to 90 days during a benefit period
  • copayment is required for days 61-
  • If 90 days are exhausted, the beneficiary can elect to use days from a non-renewable "lifetime reserve" of up to 60 additional days of IP hospital days Medicare Part A correct answer hospital insurance Medicare Part B correct answer - Medical Insurance covers most medically necessary doctor, preventative care, medical equipment, hospital outpatient services, lab tests, mental health care, and home + ambulance always pay montly premium Medicare part C (medicare advantage plan correct answer Manage care option to obtain coverage for parts A/B /D through private insurance plans contract w/ gov to administer Plans required to provide services monthly premium Medicare Part C correct answer Medicare advantage plan, combo of part a and b. covers all medical services that are needed Medicare Part D correct answer Drugs

NQF - N correct answer membership based organization designed to develop and implement a national strategy for healthcare quality measurement and reporting Outcome and assessment information correct answer A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group (HHRG) Outcome indicators correct answer Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered. Outcome Management correct answer The use of information and knowledge gained from outcomes monitoring to achieve optimal client outcomes through improved clinical decision making and service delivery. Outcome Monitoring correct answer repeated measurement over time of outcome indicators in a manner that permits causal inferences about which patient characteristics, care processes, and resources produced the observed patient outcomes. Outcomes Measurement correct answer systemic, quantitative observation, at a point in time, of outcome indicators

Performance improv correct answer The continuous study and adaptation of the functions and processes of a healthcare organization to increase the probability of achieving desired outcomes and to better meet the needs of patients. POS - Point of Service correct answer A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network. PPO - correct answer A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. Principle/Agent correct answer Doctor is agent employed by hospital (principal). Dr authorized to act on behalf of hospital but hospital is responsible. Principles of motivational interview correct answer 1) express empathy

  1. support self-efficacy
  2. roll with resistance
  3. recognize discrepancy prospective payment system correct answer A healthcare payment system used by the federal government since 1983 for reimbursing

risk sharing correct answer The process whereby an HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in cost-effectively caring for the members enrolled in the plan and assigned to a specific provider. SMART planning correct answer Specific Measurable Achievable Realistic Timely SSDI - social security disability income correct answer amount of benefit depended on work record 5-month waiting period can be approved more quickly for serious injury/illness covers a disability expecte to last 12 months or more funded by SS taxes paid by workers/employers/self employed At 65 turns into SS retirement benefit staff model HMO correct answer The most rigid HMO model. Physicians are on the staff of the HMO with some sort of salaried arrangement and provide care exclusively for the health plan enrollees.

STD - short term disab correct answer Portion of wage replaced waiting period - 7-30days from day of disability covers non-work injury/illness premium paid by ER/IE/both Ends 90-180 days after date of disability Stratifying Risk correct answer phase that determines the appropriate level of intervention by classifying the pt as low or high risk. Tools used to assess for hospice correct answer 1) Karnofsky Performance Scale (0-100%) Less than 70% = Hospice

  1. ECOG - Eastern Cooperative Oncology Group
  2. Palliative performance scale (PPS) URAC - Utilization Review Accreditation C correct answer Provides reviews and accreditation for UR services/programs provided by freestanding agencies WC correct answer Wage replacement/medical benefit No waiting period Work related illness/injury/accident premium paid by ER

individualized