Health Plan Data Scientist

The Job

This 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 Will

1. 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 interventions
• AI-enabled synthesis: applying GenAI and agentic AI tools to synthesize claims, clinical, and contract data and accelerate opportunity identification

2. 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 levers

3. 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 R
• Experience 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

What's in it for you?

• Base Pay Range: $106,200 to $182,983 annually
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• 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.

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