Elevance Health is looking to solve complex business problems and optimize member experiences within Medicare, Medicaid, and Commercial lines of business by developing and implementing predictive modeling algorithms and techniques, specifically focusing on healthcare analytics and compliance oversight.
Requirements
- Proficiency in Python, R, or SAS for statistical analysis and data modeling highly preferred.
- Advanced SQL skills with experience in querying large, complex healthcare datasets highly preferred.
- Working knowledge of Risk Adjustment methodologies (e.g., HCC, CDPS) and applicable Medicare, Medicaid, and Commercial regulations highly preferred.
- Solid understanding of healthcare regulations (specifically Risk Adjustment), and the critical thinking ability to assess risks and interpret the operational impact of policy and process changes highly preferred.
- Experience leading end-to-end data science project implementation highly preferred.
- Proficiency in data visualization tools such as Tableau or Power BI preferred.
- PhD and experience in the healthcare sector preferred.
Responsibilities
- Develops predictive models and performs statistical analyses using Python, R, or SAS to identify trends, detect anomalies, and inform compliance strategy.
- Designs and implements automated tools to support ongoing monitoring of compliance and risk adjustment metrics.
- Applies machine learning and NLP methods to various structured and unstructured data across Medicare, Medicaid, and Commercial programs.
- Writes and optimizes complex SQL queries to extract and analyze large datasets from various sources, including claims, encounters, finance, remit/return files, etc.
- Investigates data patterns, discrepancies, and trends to support regulatory reporting and internal audits.
- Partners with Risk Adjustment teams to ensure data quality and identify gaps in submissions for all three lines of business.
- Provides data-driven insights to improve internal controls and drive proactive compliance strategies.
Other
- This role requires associates to be in-office 1 day per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance.
- Ideal candidates will be able to report to one of our Pulse Point locations in Norfolk, VA, Mason, OH, Atlanta, GA, Wallingford, CT or Indianapolis, IN.
- Assesses the risk and operational impact of new or updated CMS, state Medicaid, or commercial regulations and policies.
- Collaborates cross-functionally with Legal, Quality, Operations, and IT teams to evaluate processes and support mitigation plans across lines of business.
- Mentors other data scientists.
