CLFS Analyst

Hi,

We are looking SME Analyst (CLFS) at Remote

Role: SME Analyst (CLFS)

Location : Remote

Mode: Long Term Contract

Job Description :

We are seeking a Senior CLFS Policy & Business Analyst to support the Centers for Medicare & Medicaid Services (CMS) Clinical Laboratory Fee Schedule (CLFS) program. This role serves as the subject matter expert for PAMA private payor rate reporting and CLFS payment policy, translating federal regulations and CMS guidance into business requirements, validation rules, testing scenarios, and operational processes. The ideal candidate will have deep experience with Medicare Part B reimbursement, clinical laboratory payment systems, and CMS program operations.

Key Responsibilities

• Interpret and apply PAMA Section 216, CLFS regulations, and CMS guidance related to private payor rate reporting and laboratory reimbursement.
• Translate policy and regulatory requirements into business requirements, user stories, acceptance criteria, and traceability documentation.
• Develop and maintain data validation rules for CLFS submissions, including TIN validation, HCPCS applicability, private payor rate checks, volume edits, and laboratory mappings.
• Support the end-to-end CLFS reporting lifecycle, including data collection, submission, certification, validation, weighted median calculations, rate publication, and corrections.
• Review and define test cases for system functionality, workflows, data processing, validation edits, and reporting outputs.
• Participate in system testing, defect resolution, and validation activities.
• Provide Tier 3 support for complex policy, reporting, and operational issues from laboratories, certifiers, CMS staff, and stakeholders.
• Develop and maintain user guides, operational procedures, training materials, and other program documentation.
• Support Authority to Operate (ATO), security assessments, and compliance documentation activities.
• Analyze reporting data and provide recommendations to CMS leadership regarding compliance, reporting trends, and policy impacts.
• Coordinate with CMS stakeholders, Medicare Administrative Contractors (MACs), CMS Enterprise Portal teams, and downstream payment systems.

Required Qualifications

• Bachelor’s degree in Health Administration, Public Health, Health Policy, Life Sciences, Economics, or a related field.
• 7+ years of experience in Medicare Part B payment policy, healthcare reimbursement, or clinical laboratory reimbursement.
• 3+ years of direct experience with CLFS, PAMA private payor rate reporting, or clinical laboratory billing and reimbursement operations.
• Strong knowledge of HCPCS/CPT coding and CLFS rate-setting methodologies.
• Understanding of CLIA certification requirements, applicable laboratory definitions, and Medicare reimbursement regulations.
• Experience translating federal regulations and policy into detailed business and system requirements.
• Experience supporting CMS or federal healthcare programs operating under SDLC, XLC, EPLC, or similar frameworks.
• Familiarity with CMS Enterprise Portal, IDM/EIDM, CFACTS, and CMS security processes.
• Strong analytical, documentation, and stakeholder communication skills.

Preferred Qualifications

• Master’s degree (MPH, MHA, MPP, or related field).
• Experience supporting CMS payment systems such as CLFS, PFS, OPPS, ASP, or AFS.
• Clinical laboratory reimbursement, compliance, or finance experience.
• Knowledge of Physician Fee Schedule (PFS) rulemaking processes.
• Experience with Section 508 accessibility compliance.
• Experience reviewing healthcare payment calculations and reimbursement methodologies.
• Familiarity with Agile/Scrum methodologies in federal healthcare programs.

Required Skills

• CLFS (Clinical Laboratory Fee Schedule)
• PAMA Private Payor Rate Reporting
• Medicare Part B Reimbursement
• CMS Policy and Regulatory Analysis
• HCPCS/CPT Coding
• Business Requirements Analysis
• Requirements Traceability Matrix (RTM)
• Data Validation and Quality Assurance
• User Acceptance Testing (UAT)
• CMS XLC / SDLC Methodologies
• Healthcare Compliance
• Stakeholder Management
• Technical and Functional Documentation
• Agile/Scrum

Regards,

Vignesh Aruswamy

Senior Recruiter

Phone: +1 | Email :

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