Health Plan Data Scientist

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the "12 Angry Seniors." Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. The JobThis role will be a key member of SCAN's Medical Economics Analytics team, responsible for identifying, quantifying, and helping capture total cost of care (TCOC) savings opportunities across the health plan's core medical cost management levers: clinical programs, utilization management (UM) and medical policy, payment integrity, network and contracting, benefit design, coordination of benefits (COB), and supplemental programs. The role combines strong health plan operations knowledge with data science methods and AI-enabled analytics tooling (GenAI, agentic workflows) to surface and size opportunities from claims, clinical, and contract data. This role will collaborate with clinical, network, payment integrity, and finance stakeholders to convert analytic findings into total cost of care strategy, in support of SCAN's mission of keeping seniors healthy and independent. You Will1. Apply data science and analytical methods (such as segmentation, trend analysis, statistical modeling, and GenAI-enabled synthesis) to claims, clinical, and contract data to identify, size, and prioritize total cost of care (TCOC) savings opportunities across SCAN's core medical cost management levers. Illustrative examples could include: Utilization management (UM) and medical policy: evaluating program effectiveness, medical policy application and exception patterns, and utilization outliers Payment integrity: identifying claims coding, billing, and payment accuracy opportunities (e.g., DRG validation, upcoding, duplicate payment, coordination of benefits recovery) Network and contracting: analyzing unit cost, provider relativity, and site-of-service shift to inform contracting strategy Benefit design and coordination of benefits (COB): evaluating benefit changes and COB recovery opportunities for cost and member impact Supplemental programs: assessing utilization, cost, and return on investment Clinical programs: building segmentation and predictive models to prioritize cost management interventionsAI-enabled synthesis: applying GenAI and agentic AI tools to synthesize claims, clinical, and contract data and accelerate opportunity identification2. Leverage strong health plan operations knowledge and business acumen to identify and prioritize total cost of care opportunities based on SCAN's highest-value medical cost management levers3. Create requirements, test and validate analyses, communicate findings and savings opportunity sizing to Medical Economics, Finance, Network, and Clinical business partners, and support opportunity tracking through implementation.4. Help shape and implement SCAN's medical economics analytics and AI strategy in coordination with key stakeholders across the company. Manage multiple projects at a time based on the priorities and delivery methodologies of the Medical Economics Analytics team, while also being a mentor to other analytics practitioners. Your Qualifications Bachelors Degree in statistics, mathematics, computer science, or related field required Graduate or Advanced Degree in statistics, mathematics, computer science, or related field required 3+ years working experience, preferably including healthcare industry experience 3+ years applying data science and analytical methods (e.g., statistical modeling, segmentation, trend analysis, machine learning, GenAI/agentic AI) to identify and quantify business or medical cost opportunities 1+ years of experience writing SQL code in relational database environment 2+ years of experience writing code in Python and/or RExperience with Snowflake and/or Databricks as well as Power BI.Experience with Streamlit or other data as a service apps, preferred Working knowledge of GenAI/LLM tools for synthesizing structured and unstructured health plan data (claims, clinical notes, contracts), preferred Experience in a Medicare Advantage or other managed care environment, preferred. Clinical code knowledge related to claims/utilization, preferred. Experience identifying and quantifying medical cost management opportunities across levers such as utilization management, medical policy, payment integrity, network/contracting, benefit design, coordination of benefits, and supplemental programs, preferred. Familiarity with payment integrity concepts (DRG validation, claims editing, coordination of benefits recovery, billing/coding accuracy), preferred. Understanding of claims and encounter data structures (837/835, UB-04, CMS-1500, DRG, revenue codes, ICD-10, CPT/HCPCS), preferred. Familiarity with core managed care economics (PMPM, MLR, IBNR) and total cost of care trend decomposition, preferred. Working knowledge of Medicare Advantage risk adjustment (HCC/RAF methodology), preferred. Expertise in Snowflake and Databricks for ML/AI workloads, including optimization and governance. Hands-on experience with LLM development (RAG, embeddings/vector databases, document summarization, chatbot/agent integration using LangChain / LangGraph or similar tools).Familiarity with BI tools (Power BI, Tableau, Streamlit) and integrating ML outputs for business facing solutions. Strong interpersonal skills, including excellent written and verbal communication skills. Familarity with MLOps practices, including MLflow, Azure DevOps, monitoring, and alerting. Ability to appropriately maintain confidentiality. Familiarity with Agile delivery methodologies (e.g. Scrum, SAFe) Working knowledge of health plan data domains (claims, encounters, eligibility, provider, authorizations, contracts) supporting total cost of care analytics. Fluency in managed care economics and coding conventions (PMPM, MLR, DRG, HCC/RAF) sufficient to translate model output into financial impact. Ability to translate medical cost management levers (UM, medical policy, payment integrity, network, benefit design, COB, supplemental programs) into analytic requirements and opportunity sizing frameworks. Excellent written and verbal communication skills, with ability to explain AI/ML concepts to business and technical audiences. Connects technical work to strategic health plan objectives, particularly total cost of care management across clinical, payment integrity, network, benefit design, and supplemental program levers Learns emerging AI/ML tools and healthcare regulations quickly and applies them responsibly in production environments Knowledge of real-world data (RWD), claims, EMR, and similar healthcare data; working fluency in health plan cost management concepts (PMPM, DRG, HCC/RAF risk adjustment, payment integrity, coordination of benefits) preferred

An opportunity to become part of a team that makes a difference to our members and our community every day! We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now! At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.#LI-JB1 #LI-RemoteEqual Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)