Director, Medical Economics

SCAN Health Insurance

About The Position

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 277,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter. Job Description: The Job Lead SCAN’s medical economics analytics function supporting total cost of care management, with additional scope across pharmacy economics and clinical operations analytics (UM/CM/Medical Policy). Own the analytics agenda for provider performance assessments, contract economics, network adequacy/optimization, access, and affordability, translating complex data into actions that improve SCAN’s financial performance and member outcomes. You Will Identify trends across all drivers of cost of care on a granular level (unit cost vs. utilization, site-of-care, provider/facility variation, pharmacy, post-acute, out-of-network/leakage, etc.) and deliver standardized executive updates on a regular cadence highlighting root causes, mitigation actions, forecast implications, and emerging headwinds. Develop and oversee portfolio of scored tangible activities (STAs) to quantify how medical management activities (UM/CM/Med Policy) affect total cost of care, translate initiative lift into measurable PMPM impact, and incorporate in-flight initiatives into forecasts with clear assumptions, tracking, and variance-to-plan reporting; Provide ad hoc analytics support for SCAN’s Care Delivery Assets (e.g. myPlace Health, Welcome Health, Homebase Medical, Independence at Home, Healthcare in Action) and joint venture partnerships Own provider performance and variation analytics (medical group / IPA / facility / specialist), including referral patterns, site-of-care, unit cost vs utilization decomposition, episode/case-mix aware comparisons, and intervention targeting. Lead provider contract & performance analytics to support negotiation strategy and performance terms (capitation, shared savings/loss, corridors, quality withholds, reconciliation approaches). Evaluate provider risk arrangement transitions (capitation → shared risk/at-risk models, new VBC structures), including scenario modeling, sensitivity analysis, expected ROI, downside exposure, and operational readiness considerations. Drive network adequacy and optimization analytics, including geo-mapping, access/capacity determinations, leakage/capture, opportunities to strengthen partnerships, and recommendations for network design changes. Determine impact measurement strategy for medical economics & network analytics: KPI definitions, evaluation standards, governance, and an aligned analytics roadmap. Partner with Clinical Ops (UM/CM/Medical Policy) to develop operational analytics: prior auth/denial drivers, turn-around time, escalations, approvals by policy, avoidable admissions/readmissions, SNF/post-acute patterns, and program effectiveness; establish feedback loops to policies and workflows; Partner closely with SCAN’s General Managers, Network Management, FP&A / Actuarial, Pharmacy, and other Clinical stakeholders, as well as the broader Data & Analytics team of which you’ll be a part Build pharmacy economics insight across Part D (trend, mix, formulary impact, specialty and high-cost drivers, adherence/persistence where relevant) and Part B (J-codes, buy-and-bill dynamics, site-of-care shifts, infusion/imaging policies), aligning with clinical programs and contracting strategies. Oversee risk stratification and predictive analytics to identify emerging high-cost members and utilization risk (e.g., inpatient risk, ED risk, post-acute risk, specialty drug risk), support targeted UM/CM interventions, prioritize provider/program opportunities, and monitor model performance/drift with clear governance and explainability. 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
5-7 years healthcare analytics/medical economics, including 4+ years in Medicare Advantage with MedEcon and network/contract analytics ownership, including at least 5 years of leadership experience
Demonstrated experience with pharmacy spend management (Part D and/or Part B) as it relates to affordability, clinical programs, and provider performance.
Demonstrated partnership experience with UM/CM/Medical Policy teams, including operational analytics and translating findings into policy / workflow / program changes.
Experience supporting SNP populations, including familiarity with the clinical/operational and network considerations for I-SNP models (e.g., higher acuity, longitudinal care management, facility/post-acute dynamics, interdisciplinary care teams, and tighter alignment with care delivery partners).
Expert-level medical economics: PMPM decomposition (unit cost vs utilization), trend analysis, IBNR awareness, episodes of care concepts, benchmarking, variation analysis, network leakage/capture, and provider performance measurement.
Highly self-directed operator with the judgment to independently surface the highest-impact MedEcon insights, align stakeholders, and drive measurable change end-to-end without heavy reliance on executive guidance
Strong contract analytics fluency: capitation and risk shares, withholds, corridors, reconciliation logic, and incentive design tradeoffs.

Nice To Haves

Preferred platform experience: Snowflake and/or Databricks and modern cloud data stacks; familiarity with data modeling patterns that support reliable KPI reporting.
Ability to define metrics and enable self-service analytics through semantic layers.
Advanced analytics toolkit: SQL, Python and/or R, and BI tools (Power BI/Tableau).
Experience with Ai/ML preferred: e.g., forecasting, anomaly detection, causal methods, provider segmentation, and/or LLM-enabled workflows.
Exceptional communication skills with a wide array of stakeholders: can engage effectively with senior executives (ELT/SLT), data scientists and engineers, and provider partners
Working fluency in Part D economics (specialty trend drivers, formulary impacts, utilization management levers, adherence-related measures where relevant) and Part B spend dynamics (J-codes, buy-and-bill, settings-of-care, infusion policy impacts).
Understanding of UM/CM operational levers and medical policy constructs, including how authorization criteria, care pathways, and vendor/delegated entity performance can affect both cost and member experience.
Ability to build integrated insights tying together provider performance + pharmacy + clinical ops into cohesive cost management strategies.

Responsibilities

Identify trends across all drivers of cost of care on a granular level (unit cost vs. utilization, site-of-care, provider/facility variation, pharmacy, post-acute, out-of-network/leakage, etc.) and deliver standardized executive updates on a regular cadence highlighting root causes, mitigation actions, forecast implications, and emerging headwinds.
Develop and oversee portfolio of scored tangible activities (STAs) to quantify how medical management activities (UM/CM/Med Policy) affect total cost of care, translate initiative lift into measurable PMPM impact, and incorporate in-flight initiatives into forecasts with clear assumptions, tracking, and variance-to-plan reporting
Provide ad hoc analytics support for SCAN’s Care Delivery Assets (e.g. myPlace Health, Welcome Health, Homebase Medical, Independence at Home, Healthcare in Action) and joint venture partnerships
Own provider performance and variation analytics (medical group / IPA / facility / specialist), including referral patterns, site-of-care, unit cost vs utilization decomposition, episode/case-mix aware comparisons, and intervention targeting.
Lead provider contract & performance analytics to support negotiation strategy and performance terms (capitation, shared savings/loss, corridors, quality withholds, reconciliation approaches).
Evaluate provider risk arrangement transitions (capitation → shared risk/at-risk models, new VBC structures), including scenario modeling, sensitivity analysis, expected ROI, downside exposure, and operational readiness considerations.
Drive network adequacy and optimization analytics, including geo-mapping, access/capacity determinations, leakage/capture, opportunities to strengthen partnerships, and recommendations for network design changes.
Determine impact measurement strategy for medical economics & network analytics: KPI definitions, evaluation standards, governance, and an aligned analytics roadmap.
Partner with Clinical Ops (UM/CM/Medical Policy) to develop operational analytics: prior auth/denial drivers, turn-around time, escalations, approvals by policy, avoidable admissions/readmissions, SNF/post-acute patterns, and program effectiveness; establish feedback loops to policies and workflows
Partner closely with SCAN’s General Managers, Network Management, FP&A / Actuarial, Pharmacy, and other Clinical stakeholders, as well as the broader Data & Analytics team of which you’ll be a part
Build pharmacy economics insight across Part D (trend, mix, formulary impact, specialty and high-cost drivers, adherence/persistence where relevant) and Part B (J-codes, buy-and-bill dynamics, site-of-care shifts, infusion/imaging policies), aligning with clinical programs and contracting strategies.
Oversee risk stratification and predictive analytics to identify emerging high-cost members and utilization risk (e.g., inpatient risk, ED risk, post-acute risk, specialty drug risk), support targeted UM/CM interventions, prioritize provider/program opportunities, and monitor model performance/drift with clear governance and explainability.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base Pay Range: $147,900 to $214,030 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!