Director, Clinical Intelligence

SCAN Health Insurance

About The Position

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 Job Leverage advanced analytics, AI, and reporting to drive SCAN’s clinical insights and innovation. Areas of focus include member risk stratification and predictive insights, clinical operations excellence (UM/CM/medical policy), Part C compliance analytics, and pharmacy analytics oversight (Parts B and D). Build scalable AI/analytics products that improve clinical outcomes, operational performance, affordability, and regulatory readiness. You Will Own the clinical analytics strategy and agenda, setting roadmap and prioritization in partnership with clinical, pharmacy, and compliance leaders; provide thought leadership on buy vs. build decisions including business cases, evaluation criteria, implementation approach, and long-term maintainability. Drive member risk stratification and predictive analytics, including development and deployment of models that identify emerging high-risk members (e.g., inpatient/ED risk, post-acute risk, readmission risk, specialty drug risk, etc.), with strong governance, explainability, monitoring, and drift management. Serve as a thought leader on practical GenAI adoption to improve clinical and economic outcomes and ClinOps efficiency, including identifying high-value use cases, defining governance and guardrails, measuring impact, and scaling what works. Translate predictive insights into action by partnering with UM/CM and clinical leaders to design intervention pathways, targeting rules, outreach workflows, and measurement frameworks that prove impact on utilization, experience, and cost. Lead clinical operations excellence analytics across UM/CM/medical policy, including authorization volumes and trends, denial/overturn drivers, TAT, escalation patterns, care management productivity and outcomes, post-acute management, and variation by delegated entity/provider. Own the design and evolution of a clinical insights semantic layer that standardizes key clinical/UM/Rx concepts across domains, enables governed self-service analytics, and ensures consistent, auditable reporting across dashboards, ad hoc analyses, and predictive model features. Provide targeted analytics support for care delivery assets, including performance monitoring, operational insights, and outcome evaluation, ensuring alignment with enterprise measurement standards and avoiding duplicate analytic efforts. Own Part C compliance analytics and reporting readiness, partnering with Compliance and clinical operations to build monitoring and controls for key operational requirements (e.g., timeliness, documentation, appeal/grievance-related analytics where applicable, delegation oversight support), and drive closure of gaps before they become audit findings. Oversee pharmacy analytics and data management, including trend and cost-driver analysis, specialty/high-cost management insights, site-of-care impacts (Part B buy-and-bill), formulary/UM levers, adherence-related insights where relevant, and integration of pharmacy + medical storylines for leadership decisions. Ensure reliable Rx data pipelines, reconciliation logic, and reporting accuracy (including data quality checks, anomaly detection, and root-cause workflows with PBM/vendor partners). Support clinical and Rx competitive intelligence including market trend monitoring, emerging specialty categories, formulary/benefit design signals, and implications for affordability and member experience. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN’s Vision and Goals. Other duties as assigned.

Requirements

Bachelor's Degree or equivalent experience
5 years of leadership experience
10+ years of healthcare analytics experience with progressively increasing responsibility; significant experience in Medicare Advantage strongly preferred.
Demonstrated leadership delivering advanced analytics (e.g. predictive modeling / risk stratification) and operational reporting to support clinical programs.
Experience with pharmacy analytics and financial/operational Rx concepts across Part D and at least familiarity with Part B dynamics (J-codes, buy-and-bill, site-of-care).
Experience partnering with clinical leaders, operations leaders, and vendors (e.g., PBM) to drive measurable improvement.
Comfort operating in a regulated environment with strong documentation, reproducibility, and audit-ready thinking.
Analytics / Data Science: Strong Python and/or R for modeling and analytics (feature engineering, forecasting, segmentation, anomaly detection, causal/quasi-experimental evaluation where appropriate).
Familiarity with MLOps patterns (model versioning, monitoring/drift checks, reproducible pipelines).
AI / GenAI: Experience applying ML and/or GenAI to real workflows (e.g., LLM-assisted summarization/triage, insight copilots, classification/extraction), with an emphasis on evaluation, safety/guardrails, and measurable operational impact.
Data Platform: Preferred experience with modern cloud data stacks (e.g., Snowflake or Databricks), ELT/ETL and orchestration tools, and data quality/observability practices (testing, lineage, SLAs).
Semantic Layer: Experience designing or partnering to implement a semantic layer (standardized metric definitions and governed reusable models) that supports consistent, auditable clinical/UM/Rx reporting and self-service analytics.
Data Domains: Comfort working with medical + pharmacy claims, authorizations, eligibility/enrollment, care management data, provider data, and PBM/vendor feeds; Strong knowledge of UM/CM operations and performance measurement, including how workflows, policy criteria, delegation, and timeliness requirements affect outcomes and member experience.
Working fluency in Part C operational compliance concepts and how to design analytics/control monitoring that is practical, traceable, and auditable.
Strong understanding of pharmacy economics and operations (Part D and Part B), including specialty trends, formulary/UM levers, and common data pitfalls (eligibility timing, mapping, reversals, accumulators, etc.).
Executive-grade communication: can distill complexity into crisp narratives with root cause, action plan, and expected impact.
Highly self-directed operator with the judgment to independently surface the highest-impact insights, align stakeholders, and drive measurable change end-to-end without relying on heavy executive direction

Nice To Haves

Familiarity with prompt engineering, retrieval-augmented generation (RAG), and responsible AI practices is preferred.

Responsibilities

Own the clinical analytics strategy and agenda, setting roadmap and prioritization in partnership with clinical, pharmacy, and compliance leaders; provide thought leadership on buy vs. build decisions including business cases, evaluation criteria, implementation approach, and long-term maintainability.
Drive member risk stratification and predictive analytics, including development and deployment of models that identify emerging high-risk members (e.g., inpatient/ED risk, post-acute risk, readmission risk, specialty drug risk, etc.), with strong governance, explainability, monitoring, and drift management.
Serve as a thought leader on practical GenAI adoption to improve clinical and economic outcomes and ClinOps efficiency, including identifying high-value use cases, defining governance and guardrails, measuring impact, and scaling what works.
Translate predictive insights into action by partnering with UM/CM and clinical leaders to design intervention pathways, targeting rules, outreach workflows, and measurement frameworks that prove impact on utilization, experience, and cost.
Lead clinical operations excellence analytics across UM/CM/medical policy, including authorization volumes and trends, denial/overturn drivers, TAT, escalation patterns, care management productivity and outcomes, post-acute management, and variation by delegated entity/provider.
Own the design and evolution of a clinical insights semantic layer that standardizes key clinical/UM/Rx concepts across domains, enables governed self-service analytics, and ensures consistent, auditable reporting across dashboards, ad hoc analyses, and predictive model features.
Provide targeted analytics support for care delivery assets, including performance monitoring, operational insights, and outcome evaluation, ensuring alignment with enterprise measurement standards and avoiding duplicate analytic efforts.
Own Part C compliance analytics and reporting readiness, partnering with Compliance and clinical operations to build monitoring and controls for key operational requirements (e.g., timeliness, documentation, appeal/grievance-related analytics where applicable, delegation oversight support), and drive closure of gaps before they become audit findings.
Oversee pharmacy analytics and data management, including trend and cost-driver analysis, specialty/high-cost management insights, site-of-care impacts (Part B buy-and-bill), formulary/UM levers, adherence-related insights where relevant, and integration of pharmacy + medical storylines for leadership decisions.
Ensure reliable Rx data pipelines, reconciliation logic, and reporting accuracy (including data quality checks, anomaly detection, and root-cause workflows with PBM/vendor partners).
Support clinical and Rx competitive intelligence including market trend monitoring, emerging specialty categories, formulary/benefit design signals, and implications for affordability and member experience.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base Salary Range: $147,900 to $254,798 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!
A competitive compensation and benefits program;
An annual employee bonus program;
Generous paid-time-off (PTO);
Eleven paid holidays per year;
Excellent Retirement Savings program;
A work-life balance;
An opportunity to become part of a team that makes a difference to our members and our community every day!