Medicaid SME

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

Required Skills/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 stakeholders