Commission for Case Manager Certification (CCMC) Practice Exam

The medical director is the appropriate person to escalate the situation to when a patient does not meet the required criteria. This individual typically has the authority and expertise to review complex cases, make final determinations regarding the appropriateness of care, and provide oversight on clinical decisions. The medical director is responsible for ensuring that medical policies are adhered to and often collaborates with case managers to assess and re-evaluate the patient's care plan.

In many healthcare settings, escalations are necessary when initial criteria assessments do not align with standards for patient care or insurance requirements. Since the medical director has the final say on clinical issues, they are well-suited to handle such escalations. The other roles mentioned, while important in patient care coordination and support, may not have the same level of authority or responsibility as the medical director in these situations.