CVS Health is seeking a Case Management Analyst to support data-driven, patient-centered care across its healthcare network. In this role, you will analyze member cases, clinical records, and claims data to support utilization management, identify care gaps, and improve outcomes and affordability. You'll collaborate with nurses, providers, and care teams, prepare clear documentation and reports, and help optimize workflows while maintaining strict HIPAA compliance. CVS Health offers competitive benefits, inclusive culture, and growth opportunities through training and internal mobility.
Responsibilities
- Analyze member cases to support utilization management and care coordination
- Review clinical and claims data to identify gaps in care and optimize outcomes
- Prepare case summaries, documentation, and reporting for clinical teams and leadership
- Collaborate with nurses, physicians, social workers, and pharmacy teams on care plans
- Support prior authorization, appeals, and benefits clarification processes
- Use case management and analytic tools to track caseloads and performance metrics
- Ensure compliance with clinical guidelines, HIPAA, and CVS Health policies
- Communicate with members and providers to gather information and resolve issues
- Identify high-risk or high-cost cases for targeted interventions
- Contribute to continuous improvement of case management workflows and standards
Required Skills
- Healthcare data analysis
- Case management systems (e.g., Care management platforms, EMR/EHR)
- Claims and utilization review
- Excel and data reporting tools
- Care coordination workflows
- Knowledge of health insurance and benefits
- HIPAA and regulatory compliance
- Prior authorization and appeals processes
- Written and verbal communication
- Time and caseload management
