CMCN — Certified Managed Care Nurse
Exam 2026–2027 | Comprehensive 100-
Question Practice Test with Answers &
Rationales| Pdf Access.
1. What is the primary goal of managed care?
A. Increase the number of hospital admissions
B. Provide cost-effective, high-quality healthcare
C. Eliminate specialty care
D. Reduce all healthcare services
Answer: B. Provide cost-effective, high-quality healthcare
Rationale: Managed care seeks to balance quality, access, outcomes, and healthcare costs
through coordinated and evidence-based services.
2. Which activity is most characteristic of a managed care nurse?
A. Performing surgery
B. Coordinating healthcare services
C. Prescribing controlled substances independently
D. Performing laboratory testing
Answer: B. Coordinating healthcare services
Rationale: Managed care nurses frequently coordinate services across providers, settings, and
levels of care to promote appropriate utilization and continuity.
3. Utilization management primarily focuses on:
,A. Determining whether healthcare services are medically necessary
B. Hiring hospital employees
C. Preparing hospital meals
D. Marketing medications
Answer: A. Determining whether healthcare services are medically necessary
Rationale: Utilization management evaluates whether requested or delivered services are
appropriate, necessary, and consistent with established criteria.
4. A nurse reviewing whether an inpatient admission meets established criteria is performing:
A. Case management
B. Utilization review
C. Credentialing
D. Quality auditing
Answer: B. Utilization review
Rationale: Utilization review evaluates healthcare services against criteria to determine
appropriateness and medical necessity.
5. What does medical necessity generally mean?
A. The patient prefers the service
B. The service is required for diagnosis or treatment of a condition
C. The service is always provided in a hospital
D. The service is the most expensive option
Answer: B. The service is required for diagnosis or treatment of a condition
Rationale: Medical necessity generally refers to services appropriate and needed to evaluate,
diagnose, treat, or manage a health condition according to accepted standards and applicable
coverage requirements.
6. Which approach best supports evidence-based managed care?
A. Using personal preference exclusively
B. Applying current clinical evidence with patient-specific factors
,C. Avoiding clinical guidelines
D. Using the most expensive treatment available
Answer: B. Applying current clinical evidence with patient-specific factors
Rationale: Evidence-based practice integrates research evidence, clinical expertise, and patient
circumstances and preferences.
7. What is the primary purpose of case management?
A. Increase healthcare utilization
B. Coordinate services to achieve appropriate outcomes
C. Replace all physicians
D. Eliminate patient education
Answer: B. Coordinate services to achieve appropriate outcomes
Rationale: Case management helps patients navigate complex healthcare systems while
coordinating resources and promoting quality outcomes.
8. Which patient is most appropriate for intensive case management?
A. Healthy adult needing a routine physical
B. Patient with multiple chronic diseases and frequent hospitalizations
C. Patient requesting a routine vaccination
D. Patient with an uncomplicated minor abrasion
Answer: B. Patient with multiple chronic diseases and frequent hospitalizations
Rationale: Complex patients with multiple conditions, high utilization, or barriers to care
commonly benefit from intensive case management.
9. A nurse identifies that a patient repeatedly misses appointments because of transportation
problems. What is the best intervention?
A. Discharge the patient from the program
B. Identify transportation resources
C. Tell the patient to find transportation independently
D. Ignore the problem
, Answer: B. Identify transportation resources
Rationale: Managed care emphasizes addressing barriers that interfere with access, adherence,
and outcomes.
10. Which is an example of a social determinant of health?
A. Blood pressure
B. Transportation access
C. Serum sodium
D. Heart rate
Answer: B. Transportation access
Rationale: Transportation, housing, food security, income, education, and social support can
significantly influence health outcomes.
11–20: Managed Care Principles
11. A health maintenance organization (HMO) generally emphasizes:
A. Unlimited out-of-network care without restrictions
B. Coordinated care within a defined network
C. No preventive services
D. Fee-for-service billing exclusively
Answer: B. Coordinated care within a defined network
Rationale: HMOs generally use provider networks and coordinated care structures to manage
quality and utilization.
12. A preferred provider organization (PPO) typically allows:
A. No provider choice
B. Use of both in-network and out-of-network providers
C. Only emergency services
D. Only government hospitals
Answer: B. Use of both in-network and out-of-network providers
Exam 2026–2027 | Comprehensive 100-
Question Practice Test with Answers &
Rationales| Pdf Access.
1. What is the primary goal of managed care?
A. Increase the number of hospital admissions
B. Provide cost-effective, high-quality healthcare
C. Eliminate specialty care
D. Reduce all healthcare services
Answer: B. Provide cost-effective, high-quality healthcare
Rationale: Managed care seeks to balance quality, access, outcomes, and healthcare costs
through coordinated and evidence-based services.
2. Which activity is most characteristic of a managed care nurse?
A. Performing surgery
B. Coordinating healthcare services
C. Prescribing controlled substances independently
D. Performing laboratory testing
Answer: B. Coordinating healthcare services
Rationale: Managed care nurses frequently coordinate services across providers, settings, and
levels of care to promote appropriate utilization and continuity.
3. Utilization management primarily focuses on:
,A. Determining whether healthcare services are medically necessary
B. Hiring hospital employees
C. Preparing hospital meals
D. Marketing medications
Answer: A. Determining whether healthcare services are medically necessary
Rationale: Utilization management evaluates whether requested or delivered services are
appropriate, necessary, and consistent with established criteria.
4. A nurse reviewing whether an inpatient admission meets established criteria is performing:
A. Case management
B. Utilization review
C. Credentialing
D. Quality auditing
Answer: B. Utilization review
Rationale: Utilization review evaluates healthcare services against criteria to determine
appropriateness and medical necessity.
5. What does medical necessity generally mean?
A. The patient prefers the service
B. The service is required for diagnosis or treatment of a condition
C. The service is always provided in a hospital
D. The service is the most expensive option
Answer: B. The service is required for diagnosis or treatment of a condition
Rationale: Medical necessity generally refers to services appropriate and needed to evaluate,
diagnose, treat, or manage a health condition according to accepted standards and applicable
coverage requirements.
6. Which approach best supports evidence-based managed care?
A. Using personal preference exclusively
B. Applying current clinical evidence with patient-specific factors
,C. Avoiding clinical guidelines
D. Using the most expensive treatment available
Answer: B. Applying current clinical evidence with patient-specific factors
Rationale: Evidence-based practice integrates research evidence, clinical expertise, and patient
circumstances and preferences.
7. What is the primary purpose of case management?
A. Increase healthcare utilization
B. Coordinate services to achieve appropriate outcomes
C. Replace all physicians
D. Eliminate patient education
Answer: B. Coordinate services to achieve appropriate outcomes
Rationale: Case management helps patients navigate complex healthcare systems while
coordinating resources and promoting quality outcomes.
8. Which patient is most appropriate for intensive case management?
A. Healthy adult needing a routine physical
B. Patient with multiple chronic diseases and frequent hospitalizations
C. Patient requesting a routine vaccination
D. Patient with an uncomplicated minor abrasion
Answer: B. Patient with multiple chronic diseases and frequent hospitalizations
Rationale: Complex patients with multiple conditions, high utilization, or barriers to care
commonly benefit from intensive case management.
9. A nurse identifies that a patient repeatedly misses appointments because of transportation
problems. What is the best intervention?
A. Discharge the patient from the program
B. Identify transportation resources
C. Tell the patient to find transportation independently
D. Ignore the problem
, Answer: B. Identify transportation resources
Rationale: Managed care emphasizes addressing barriers that interfere with access, adherence,
and outcomes.
10. Which is an example of a social determinant of health?
A. Blood pressure
B. Transportation access
C. Serum sodium
D. Heart rate
Answer: B. Transportation access
Rationale: Transportation, housing, food security, income, education, and social support can
significantly influence health outcomes.
11–20: Managed Care Principles
11. A health maintenance organization (HMO) generally emphasizes:
A. Unlimited out-of-network care without restrictions
B. Coordinated care within a defined network
C. No preventive services
D. Fee-for-service billing exclusively
Answer: B. Coordinated care within a defined network
Rationale: HMOs generally use provider networks and coordinated care structures to manage
quality and utilization.
12. A preferred provider organization (PPO) typically allows:
A. No provider choice
B. Use of both in-network and out-of-network providers
C. Only emergency services
D. Only government hospitals
Answer: B. Use of both in-network and out-of-network providers
