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
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.
Skills:
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 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
Experience implementing and managing Provider Enrollment systems
Experience implementing claims systems and managing claims data
Familiarity with CMS reporting and compliance requirements
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