CARE MANAGER CERTIFICATION EXAM 2026/2027 TEST | WITH
COMPREHENSIVE QUESTIONS AND VERIFIED ANSWERS | GRADED
A+
When does care coordination begin and end - ANSWER Prior to admission for elective procedure -
30-90 days after discharge.
Pay for performance models have a greater emphasis on - ANSWER Value based purchasing,
readmission, Hospital acquired conditions
What factors effect value based purchasing? - ANSWER quality of care,, reduce adverse
events/safety, improving patient experience, efficiency/delivering low cost care.
What does the Acronym LACE stand for in the Lace Assesment tool.. - ANSWER LENGTH of Stay,
ACUITY of Admission, COMORBIDITY, EMERGENCY Deoartment Visits.
What are the 8 ps in The Society for Hospital Medicines Project Boost Risk Assesment - Readmission
Assement - ANSWER Problems with Medications, Psychological,
Principal Diagnosis,
Physical Limitations,
Poor Health Literacy,
Patient Support,
Prior Hospitalization,
Palliative Care
Components of RED ( Reengineered discharge) - ANSWER Asses need for translator,
sched f/u appointments,
f/u on outstanding test results,
coordinate post d/c out-patient services,
obtaining medications
national d/c guidelines,
d/c teaching,
educate on what to do if problems arise,
,assess pt understanding,
d/c summary to outside providers, d/c follow up call.
After Hospital Care Plan (AHCP)
In regards to Value Based Pricing/payments, What factors weigh heavily in clinical care outcomes? -
ANSWER mortality
In regards to Value Based Pricing/payments, what factors are considered in Patient experience of
Care - ANSWER staff communication,
receiving written d/c information, warning signs,
explanation of medications,
pain management,
overall experience.
In regards to Value Based Pricing/payments, what factors are used to determine payout based on
efficiency. - ANSWER spending per beneficiary, 3 days prior to admission to 30 days post d/c.
Resource utilization,
length of stay,
post acute services.
In regards to Value Based Pricing/payments, what factors are used to determine payout for safety? -
ANSWER Various patient safety factors and infection rates
What is the definition of health literacy ? - ANSWER the degree to which individuals have the
capacity to obtain, process and understand basic health information and services needed to make
appropriate health decisions.
What are social determinants of health? - ANSWER The structural determinants and conditions in
which people are born, grow, live, work, and age which have a significant impact on health
outcomes.
What are the components of a psychosocial history - ANSWER family composition, education,
occupation, psychological and/or psychiatric functioning, living siuation, support system,
transportation concerns, life changes or stressor, cooing skills, social/ community involvement,
spiritual aspects and concerns, self care, cognitive or perception problems, financial concerns.
, What is the required assessment for admission to a nursing home for a patient with a diagnosis of
mental retardation or mental illness to assure appropriate placement - ANSWER Federal Pre-
Admission Screening and Resident Review. Some states may require additional screening tools.
What factors effect social determinents of health? - ANSWER economic stability, neighborhood and
built environment, education, food, community and social context, health and health care.
Required assessment for admission to a nursing home for a patient with a diagnosis of mental
retardation - ANSWER Federal Pre-Admission Screening and Resident Review. Some states may
require additional screen in ng tools.
What is utilization and review? - ANSWER reviewing patients clinical condition and providing decis I
on support to MD on bed and billing status. ie observation, Out Pt, In-Patient. and being prepared to
justify medical necessity. Additional certification is required for admission Ions longer than 20 days.
components of the psychosocial history - ANSWER family composition, education, occupation,
psychological and/or psychiatric functioning, living siuation, support system, transportation concerns,
life changes or stressor, cooing skills, social/ community involvement, spiritual aspects and concerns,
self care, cognitive or perception problems, financial concerns.
Physician certification or recertification for admissions longer than ____ days requires what
documentation? - ANSWER 20 days.
Reason for hoslitalization estimated length of continued stay, post acute plans,
if patient is only waiting on SNF placement must indicate reason for delay.
What is a condition code 44? - ANSWER For Medicare services, when a UM review team has
determined that an order for inpatient admission is not medically necessary. Order can be changed
to observation. The admission will be billed under part B Medicare only
What requirements must be met to bill a Condition Code 44? - ANSWER The change must be made
prior to discharge.
The claim has not been submitted, The MD concurs with the UM decision,
occurrence is documented in the medical record.
What are the key elements of CM planning? - ANSWER Patient engagement,
COMPREHENSIVE QUESTIONS AND VERIFIED ANSWERS | GRADED
A+
When does care coordination begin and end - ANSWER Prior to admission for elective procedure -
30-90 days after discharge.
Pay for performance models have a greater emphasis on - ANSWER Value based purchasing,
readmission, Hospital acquired conditions
What factors effect value based purchasing? - ANSWER quality of care,, reduce adverse
events/safety, improving patient experience, efficiency/delivering low cost care.
What does the Acronym LACE stand for in the Lace Assesment tool.. - ANSWER LENGTH of Stay,
ACUITY of Admission, COMORBIDITY, EMERGENCY Deoartment Visits.
What are the 8 ps in The Society for Hospital Medicines Project Boost Risk Assesment - Readmission
Assement - ANSWER Problems with Medications, Psychological,
Principal Diagnosis,
Physical Limitations,
Poor Health Literacy,
Patient Support,
Prior Hospitalization,
Palliative Care
Components of RED ( Reengineered discharge) - ANSWER Asses need for translator,
sched f/u appointments,
f/u on outstanding test results,
coordinate post d/c out-patient services,
obtaining medications
national d/c guidelines,
d/c teaching,
educate on what to do if problems arise,
,assess pt understanding,
d/c summary to outside providers, d/c follow up call.
After Hospital Care Plan (AHCP)
In regards to Value Based Pricing/payments, What factors weigh heavily in clinical care outcomes? -
ANSWER mortality
In regards to Value Based Pricing/payments, what factors are considered in Patient experience of
Care - ANSWER staff communication,
receiving written d/c information, warning signs,
explanation of medications,
pain management,
overall experience.
In regards to Value Based Pricing/payments, what factors are used to determine payout based on
efficiency. - ANSWER spending per beneficiary, 3 days prior to admission to 30 days post d/c.
Resource utilization,
length of stay,
post acute services.
In regards to Value Based Pricing/payments, what factors are used to determine payout for safety? -
ANSWER Various patient safety factors and infection rates
What is the definition of health literacy ? - ANSWER the degree to which individuals have the
capacity to obtain, process and understand basic health information and services needed to make
appropriate health decisions.
What are social determinants of health? - ANSWER The structural determinants and conditions in
which people are born, grow, live, work, and age which have a significant impact on health
outcomes.
What are the components of a psychosocial history - ANSWER family composition, education,
occupation, psychological and/or psychiatric functioning, living siuation, support system,
transportation concerns, life changes or stressor, cooing skills, social/ community involvement,
spiritual aspects and concerns, self care, cognitive or perception problems, financial concerns.
, What is the required assessment for admission to a nursing home for a patient with a diagnosis of
mental retardation or mental illness to assure appropriate placement - ANSWER Federal Pre-
Admission Screening and Resident Review. Some states may require additional screening tools.
What factors effect social determinents of health? - ANSWER economic stability, neighborhood and
built environment, education, food, community and social context, health and health care.
Required assessment for admission to a nursing home for a patient with a diagnosis of mental
retardation - ANSWER Federal Pre-Admission Screening and Resident Review. Some states may
require additional screen in ng tools.
What is utilization and review? - ANSWER reviewing patients clinical condition and providing decis I
on support to MD on bed and billing status. ie observation, Out Pt, In-Patient. and being prepared to
justify medical necessity. Additional certification is required for admission Ions longer than 20 days.
components of the psychosocial history - ANSWER family composition, education, occupation,
psychological and/or psychiatric functioning, living siuation, support system, transportation concerns,
life changes or stressor, cooing skills, social/ community involvement, spiritual aspects and concerns,
self care, cognitive or perception problems, financial concerns.
Physician certification or recertification for admissions longer than ____ days requires what
documentation? - ANSWER 20 days.
Reason for hoslitalization estimated length of continued stay, post acute plans,
if patient is only waiting on SNF placement must indicate reason for delay.
What is a condition code 44? - ANSWER For Medicare services, when a UM review team has
determined that an order for inpatient admission is not medically necessary. Order can be changed
to observation. The admission will be billed under part B Medicare only
What requirements must be met to bill a Condition Code 44? - ANSWER The change must be made
prior to discharge.
The claim has not been submitted, The MD concurs with the UM decision,
occurrence is documented in the medical record.
What are the key elements of CM planning? - ANSWER Patient engagement,
