SME Medicaid SME MS Medicaid

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

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

Provide expert guidance on Medicaid data structure and relationships including:

• Eligibility and enrollment data

• Demographic and coverage information

• Managed care enrollment and attribution

• Member identifiers and cross-system matching

• Provider enrollment and credentialing

• Provider taxonomy and specialty classifications

• Provider affiliations and group relationships

• National Provider Identifier (NPI) integration

• 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 Organization (MCO) encounter data

• Capitation payments

• Managed care reporting requirements

• Encounter-to-claim mapping and validation

• Advise on data requirements for fraud waste and abuse detection

• Assist with data mapping and validation of data models

• Support development of analytics rules and investigative workflows

• Identify data quality issues and recommend remediation

• Define use cases and investigative scenarios

• Ensure Medicaid policies are correctly implemented in the PI tool

• Work with vendors and system integrators on data ingestion and transformation

• Support data validation testing and reconciliation

• Participate in requirements gathering and design sessions

• Provide business context for technical teams

• Review system outputs for accuracy

• Support User Acceptance Testing (UAT)

Work with:

• Program Integrity leadership

• Data analytics teams

• Medicaid program staff

• IT and data architecture teams

• System implementation vendors

• Managed Care oversight teams

• Medicaid data domain documentation validation

• Data mapping and dictionary validation

• Program Integrity business rules validation

• Data quality assessments and recommendations

• Configuration validation documentation

• UAT validation feedback

• Implementation support reports

The Medicaid SME must have:

• 15 years of experience working with Medicaid program data and operations

• 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 similar platforms

• Strong understanding of Medicaid 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

• Experience implementing and managing Provider Enrollment systems

• Experience implementing claims systems and managing claims data

• Familiarity with CMS reporting and compliance requirements