Commission for Case Manager Certification (CCMC) Exam 2025 – 400 Free Practice Questions to Pass the Exam

The role of a utilization management registered nurse primarily involves ensuring that the healthcare services provided to patients are necessary and appropriate based on established criteria. In the context of claim denials, they do not possess the authority to deny claims outright. Instead, their work supports the process of evaluating the medical necessity and appropriateness of services rendered, which can influence decisions about claims.

By conducting assessments and reviews, these professionals provide critical information to other stakeholders, such as the claims department or insurance providers, who make the final decisions regarding denials or approvals. Their focus is not on denying claims but rather on ensuring that all necessary documentation and justification for services are in place, which can help in reducing the likelihood of a denial.

Through their specialized training and experience, utilization management nurses play a vital role in the healthcare system, working collaboratively with various teams to promote quality patient care and facilitate the claims process without having the final say on denial decisions.