Medicaid Subject Matter Expert (SME) (Onsite)

Jackson, MO - USA

Monthly Salary: Not Disclosed

Posted on: 3 hours ago

Vacancies: 1 Vacancy

Job Summary

Job Title: Medicaid Subject Matter Expert (SME) (Onsite)

Location: Jackson MS

Duration: 12 Months

Job Description:

The Medicaid SME will provide subject matter expertise related to Medicaid program data policies and operational workflows to support the successful implementation and operationalization of the Program Integrity (PI) tool.

The SME will collaborate with technical teams program staff vendors and project leadership to ensure the PI solution effectively leverages Medicaid data to detect prevent and investigate fraud waste and abuse.

Key Responsibilities:

Data Domain Expertise - Provide expert guidance related to the structure relationships and usage of Medicaid data domains including:

Member Data:

Eligibility and enrollment data
Demographic and coverage information
Managed care enrollment and attribution
Member identifiers and cross-system matching

Provider Data:

Provider enrollment and credentialing
Provider taxonomy and specialty classifications
Provider affiliations and group relationships
National Provider Identifier (NPI) and provider registry integration

Claims Data:

Professional institutional and pharmacy claims
Claim lifecycle and adjudication processes
Service codes (CPT HCPCS ICD DRG)
Payment and encounter processing
Claims adjustments voids and resubmissions

Managed Care Data:

Managed Care Organization (MCO) encounter data
Capitation payments
Managed care reporting requirements
Encounter-to-claim mapping and validation

Program Integrity Support:

Advising on data requirements for fraud waste and abuse detection
Assisting with data mapping and data model validation for the PI tool
Supporting development of analytics rules and investigative workflows
Identifying data quality issues and remediation strategies
Helping define use cases and investigative scenarios
Ensuring accurate interpretation of Medicaid policy and program rules within the tool
Implementation Support:
Collaborating with system integrators and vendors on data ingestion and transformation
Supporting data validation testing and reconciliation
Participating in requirements gathering and design sessions
Providing business context for technical teams
Reviewing system outputs for accuracy and relevance
Supporting User Acceptance Testing (UAT)

Stakeholder Collaboration:

Program Integrity leadership
Data analytics teams
Medicaid program staff
IT and data architecture teams
System implementation vendors
Managed Care oversight teams

Work Products:

Medicaid data domain documentation validation
Data mapping and data dictionary validation
Program Integrity use cases and business rules validation
Data quality assessments and recommendations
Support documentation for system configuration validation
UAT participation and validation feedback
Implementation support reports and findings validation

Required Skills/Experience

The Medicaid SME must possess:

Minimum of 15 years of experience working with Medicaid program data and operations
Demonstrated expertise in the following Medicaid data domains:

Member/Eligibility data
Provider enrollment data
Claims and encounter data
Managed care program data

Experience working with Gainwell Medicaid Management Information Systems (MMIS) or successor platforms
Strong understanding of Medicaid program policies and regulatory requirements
Experience supporting large system implementations or modernization projects
Ability to communicate complex Medicaid data concepts to technical and non-technical stakeholders

Preferred/Not Required

Experience implementing and managing Provider Enrollment systems
Experience implementing claims systems and managing claims data
Familiarity with CMS reporting and compliance requirements

Job Title: Medicaid Subject Matter Expert (SME) (Onsite) Location: Jackson MS Duration: 12 Months Job Description: The Medicaid SME will provide subject matter expertise related to Medicaid program data policies and operational workflows to support the successful implementation and operationaliz...