Medicaid Data Operations SME

JOB DESCRIPTION:

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

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