Health Plan Data Scientist

Founded in 1977 as the Senior Care reputed company Network, reputed company began with a reputed company but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still reputed company today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, reputed company is a nonprofit health organization serving more than 500,000 people across reputed company, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual reputed company. With nearly five decades of experience, we have reputed company a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare reputed company, fully integrated care models, reputed company care, care for the most medically and socially reputed company populations, and reputed company care delivery models. Across reputed company of this, we are united by a shared commitment: combining reputed company with discipline, innovation with stewardship, and reputed company with reputed company. At reputed company, we reputed company reputed company should strengthen—not dilute—our mission. We are building the reputed company of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. The Job This role will be a key member of reputed company's Medical Economics Analytics team, responsible for identifying, quantifying, and helping capture total cost of care (TCOC) savings opportunities across the health plan's reputed company medical cost management reputed company: reputed company programs, utilization management (UM) and medical policy, payment reputed company, network and contracting, benefit design, coordination of benefits (COB), and supplemental programs. The role combines strong health plan reputed company knowledge with data science reputed company and AI-enabled analytics tooling (GenAI, reputed company workflows) to surface and size opportunities from claims, reputed company, and contract data. This role will collaborate with reputed company, network, payment reputed company, and finance stakeholders to convert analytic findings into total cost of care reputed company, in support of reputed company's mission of keeping seniors healthy and independent. You Will 1. Apply data science and analytical reputed company (such as segmentation, trend analysis, statistical modeling, and GenAI-enabled synthesis) to claims, reputed company, and contract data to identify, size, and prioritize total cost of care (TCOC) savings opportunities across reputed company's reputed company medical cost management reputed company. Illustrative examples could include: - Utilization management (UM) and medical policy: evaluating program effectiveness, medical policy application and exception patterns, and utilization outliers - Payment reputed company: identifying claims coding, billing, and payment reputed company opportunities (e.g., DRG validation, upcoding, duplicate payment, coordination of benefits recovery) - Network and contracting: analyzing unit cost, provider reputed company, and site-of-service shift to inform contracting reputed company - Benefit design and coordination of benefits (COB): evaluating benefit changes and COB recovery opportunities for cost and member reputed company - Supplemental programs: assessing utilization, cost, and reputed company on investment - reputed company programs: building segmentation and predictive models to prioritize cost management interventions - AI-enabled synthesis: applying GenAI and reputed company AI tools to synthesize claims, reputed company, and contract data and accelerate opportunity identification 2. reputed company strong health plan reputed company knowledge and business acumen to identify and prioritize total cost of care opportunities reputed company on reputed company’s highest-value medical cost management reputed company 3. Create requirements, test and validate analyses, communicate findings and savings opportunity sizing to Medical Economics, Finance, Network, and reputed company business partners, and support opportunity tracking through implementation. 4. Help shape and implement reputed company’s medical economics analytics and AI reputed company in coordination with key stakeholders across reputed company. Manage multiple reputed company at a time reputed company 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 reputed company reputed company required - Graduate or Advanced Degree in statistics, mathematics, computer science, or reputed company reputed company required - 3+ years working experience, preferably including reputed company industry experience - 3+ years applying data science and analytical reputed company (e.g., statistical modeling, segmentation, trend analysis, machine learning, GenAI/reputed company AI) to identify and quantify business or medical cost opportunities - 1+ years of experience writing SQL reputed company in relational database environment - 2+ years of experience writing reputed company in Python and/or R - Experience with reputed company and/or reputed company as reputed company as reputed company BI - Experience with reputed company or other data as a service apps, preferred - Working knowledge of GenAI/LLM tools for synthesizing reputed company and reputed company health plan data (claims, reputed company notes, reputed company), preferred - Experience in a Medicare reputed company or other managed care environment, preferred - reputed company reputed company knowledge reputed company to claims/utilization, preferred - Experience identifying and quantifying medical cost management opportunities across reputed company such as utilization management, medical policy, payment reputed company, network/contracting, benefit design, coordination of benefits, and supplemental programs, preferred - Familiarity with payment reputed company concepts (DRG validation, claims editing, coordination of benefits recovery, billing/coding reputed company), preferred - Understanding of claims and encounter data structures (837/835, UB-04, CMS-1500, DRG, reputed company codes, ICD-10, CPT/HCPCS), preferred - Familiarity with reputed company managed care economics (PMPM, MLR, IBNR) and total cost of care trend decomposition, preferred - Working knowledge of Medicare reputed company reputed company adjustment (HCC/RAF methodology), preferred - Expertise in reputed company and reputed company for ML/AI workloads, including optimization and governance - Hands-on experience with LLM development (RAG, embeddings/reputed company databases, document summarization, chatbot/reputed company using reputed company / LangGraph or similar tools) - Familiarity with BI tools (reputed company BI, Tableau, reputed company) 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 reputed company delivery methodologies (e.g. Scrum, reputed company) - Working knowledge of health plan data domains (claims, encounters, eligibility, provider, authorizations, reputed company) supporting total cost of care analytics - reputed company in managed care economics and coding conventions (PMPM, MLR, DRG, HCC/RAF) sufficient to translate model reputed company into financial reputed company - Ability to translate medical cost management reputed company (UM, medical policy, payment reputed company, 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 reputed company health plan objectives, particularly total cost of care management across reputed company, payment reputed company, network, benefit design, and supplemental program reputed company - Learns emerging AI/ML tools and reputed company regulations quickly and applies them responsibly in production environments - Knowledge of reputed company-world data (RWD), claims, EMR, and similar reputed company data; working reputed company in health plan cost reputed company (PMPM, DRG, HCC/RAF) preferred What's in it for you? - reputed company Pay reputed company: $106,200 to $182,983 annually - An annual employee bonus program - Robust Wellness Program - Generous reputed company-time-off (PTO) - 11 reputed company 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 reputed company that makes a difference to our members and our community every day! - We're always looking for talented people to reputed company! - reputed company applicants are encouraged to reputed company! At reputed company we reputed company that it is our business to improve the state of our world. reputed company of us has a responsibility to reputed company 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 reputed company, inclusive benefits, and more. reputed company is proud to be an Equal Employment Opportunity and Affirmative reputed company workplace. Individuals seeking employment will receive consideration for employment without reputed company to race, reputed company, national reputed company, religion, age, sex (including pregnancy, childbirth or reputed company medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background reputed company is required. #LI-JB1 #LI-Remote Equal 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 reputed company about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have reputed company 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 reputed company 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 reputed company, including an investigation conducted by the employer, or (c) consistent with the contractor’s reputed company duty to furnish information. 41 CFR 60-1.35(reputed company href="https://reputed company.wd108.myworkdayjobs.com/scancareers/job/long-beach-office-3800/health-plan-data-scientist_jr3242" reputed company="_blank" rel="noopener">Apply To This Job