Medicaid SME

We have a 1-year 100% onsite Medicaid SME contract in Jackson MS with the possibility of renewal. The anticipated start date is April 15 2026.

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

Minimum Qualifications

• 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

Desirable Qualifications

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

Minimum Application Requirements

Your application will be disqualified if you do not meet all these minimum application requirements.

• Must meet or exceed the Minimum Qualifications.
• Must be a current resident of the United States.
• Must have current work authorization for the United States.
• Must be a direct hire.

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