Medicaid -MCO- Business Analyst

Contract to Hire role

Remote USA

JC: In Process

Rate: $35/Hr on W2 with out benefits

Business Analyst Job Description - Medicaid Membership (MCO Experience Required)

Key Responsibilities

• Act as the liaison between MCO business operations, IT teams and state agencies.
• Interact with Clients. Prepare a roadmap for Implementation of Software. Contribute in design related discussions
• Gather, analyze, and document business requirements related to Medicaid membership management, eligibility, enrollment, premium billing, and reconciliation.
• Support compliance with state and federal Medicaid regulations, ensuring system functionality meets CMS and state-specific rules.
• Translate business needs into functional requirements, use cases, and user stories for membership systems and portals.
• Partner with operations teams to monitor, automate and improve member onboarding, disenrollment, and work requirement compliance workflows.
• Work with integration teams on data exchanges with state Medicaid agencies (eligibility files, roster updates, Work requirement compliance reporting).
• Develop test cases, perform UAT (User Acceptance Testing), and validate system enhancements before production releases.
• Provide business analysis for operational reports, dashboards, and performance metrics.
• Collaborate with cross-functional teams (call center, claims, care management) to ensure membership data accuracy and timely resolution of issues.
• Support audits and reporting requirements by maintaining clear documentation and traceability of business rules.
• Contribute to RFI/RFP responses

Required Skills & Experience

• Minimum 5+ years working at an MCO or Medicaid-focused environment in business operations and systems.
• Experience supporting or implementing Medicaid membership SaaS or hosted platforms.
• Good understanding of MCO operations and systems around Medicaid, MLTC, CHIP, DSNP lines of businesses
• Familiarity with work requirement tracking, exemptions, and compliance reporting.
• Strong understanding of Medicaid membership lifecycle: eligibility, enrollment, disenrollment, premium billing, reconciliation, and reporting.
• Familiarity with state Medicaid agency interactions (834/820 transactions, roster management, state audits, compliance reporting).
• Experience with regulatory compliance and CMS/state Medicaid rules (including work requirements).
• Hands-on experience with Medicaid membership systems, portals, or core admin platforms.
• Proficiency in business requirements gathering, process mapping, and writing functional specifications.
• Strong knowledge of data flows, integration methods, and file/API exchanges between MCOs and state agencies.
• Analytical skills to perform gap analysis, root cause analysis, and recommend operational improvements.
• Excellent documentation skills (BRD, FSD, user stories, workflows, SOPs).
• Communication skills to effectively engage with business users, IT teams, and external regulators.

• Knowledge of healthcare data standards (HIPAA, 834, 820, HL7, FHIR) would be a plus.
• Background in process automation, analytics, or dashboarding for Medicaid membership