Medicaid Subject Matter Expert (SME)

Project Description and Job Skills Set

• 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

Required Skills and Experience:

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 stakeholder

Preferred (Not required)

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