Medicaid SME or Medicaid Expert

Title: Medicaid Subject Matter Expert (SME)
Location: 550 High Street, Jackson, Mississippi 39201
Duration: 1 Year with (Renewable up to 5 years)

The Medicaid Subject Matter Expert (SME) will provide deep domain expertise related to Medicaid program data, policies, and operational workflows to support the implementation of a Program Integrity (PI) platform.
The SME will collaborate with technical teams, program staff, vendors, and leadership to ensure the system effectively leverages Medicaid data to detect and prevent fraud, waste, and abuse (FWA).

Key Responsibilities

Provide guidance on the structure and relationships across Medicaid data domains:

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) integration

Claims Data

• Professional, institutional, and pharmacy claims
• Claim lifecycle and adjudication
• Service codes (CPT, HCPCS, ICD, DRG)
• Payment and encounter processing
• Claims adjustments and resubmissions

Managed Care Data

• Managed Care Organization (MCO) encounter data
• Capitation payments
• Managed care reporting requirements
• Encounter-to-claim validation

Program Integrity Support

• Provide guidance on fraud, waste, and abuse detection strategies
• Support data mapping and data model validation
• Assist with development of analytics and business rules
• Identify data quality issues and remediation strategies
• Help define investigation workflows and use cases
• Ensure system alignment with Medicaid policies and program rules

Implementation Support

• Collaborate with system integrators and vendors
• Support data ingestion, transformation, and validation
• Participate in requirements gathering and design workshops
• Provide business context to technical teams
• Review system outputs for accuracy
• Support User Acceptance Testing (UAT)

Stakeholder Collaboration

Work closely with:

• Program Integrity Leadership
• Medicaid Program Staff
• Data Analytics Teams
• IT and Data Architecture Teams
• Implementation Vendors
• Managed Care Oversight Teams

Deliverables

• Medicaid data documentation validation
• Data mapping and data dictionary validation
• Program Integrity use case documentation
• Data quality assessments
• System configuration validation
• UAT feedback and testing results
• Implementation support reports

Required Qualifications

• 15+ years of experience working with Medicaid program data and operations
• Expertise in Medicaid data domains:
• o Member / Eligibility Data
• o Provider Enrollment Data
• Claims & Encounter Data
• Managed Care Program Data
• Experience working with Gainwell MMIS or similar Medicaid systems
• Strong understanding of Medicaid policies and regulatory requirements
• Experience supporting large system implementations or modernization projects
• Ability to communicate complex Medicaid data concepts to both technical and business stakeholders

Preferred Qualifications

• Experience implementing Provider Enrollment Systems
• Experience implementing Claims Processing Systems
• Knowledge of CMS reporting and compliance requirements

Regards,

Nick Arthur (Nizam)

Associate Director, Recruitment

Pull Skill Technologies Inc.

Direct: +1 551-272-o197