Medicaid SME

Job Title :: Medicaid SME

Duration :: ASAP- 4/14/2027 (Funded for Fiscal year and may go longer)

Worksite Address :: Jackson MS 39211 Onsite

Department: State of Mississippi -Medicaid

Interview Type:: In-Person and Webcam Both

Position Description and Job Skill Set

Description of the job functions the contractor will be expected to perform.

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:

Required Skills/Experience

Provide the minimum required skills and/or experience the contractor must possess to qualify for this position. These requirements will be transferred to the Score Sheet and candidates without these requirements reflected on their resume will

NOT be presented to the manager for consideration.

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

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

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

Note:

- Applicants who do not meet all of the required skills/experience minimums may not be considered further.

- The awarded applicant will be required to execute a Business Associate Agreement (BAA) with DOM.

- The period of performance will be for one-year intervals with the ability to renew for up to five (5) years based on mutual agreement of the parties.

Best Regards

Ibraheem Mohammad

Momento USA Exceeding Customer Expectations

Email:

440 Benigno Blvd Unit#A 2nd Floor. Bellmawr NJ 08031

Interstate Business Park

Direct: / Desk: X 1019 / Fax:

Web:

Note: Momento USA is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex pregnancy sexual orientation gender identity national origin age protected veteran status or disability status.