Medicaid SME

Job Title: Medicaid SME

Location: Jackson MS 100% onsite required

Duration: 12 months Contract with possibility to extension

Overview: 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

• Advise on data requirements for fraud waste and abuse detection
• Assist with data mapping and data model validation for the PI tool
• Support the development of analytics rules and investigative workflows
• Identify data quality issues and recommend remediation strategies
• Help define use cases and investigative scenarios
• Ensure accurate interpretation of Medicaid policy and program rules within the tool

Implementation Support

• Collaborate with system integrators and vendors 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 and relevance
• Support 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

Notes

• 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 one-year intervals with the ability to renew for up to five (5) years based on mutual agreement of the parties.

Required Qualifications

The Medicaid SME must possess:

• A 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

Additional Preferred Experience

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