Business Analyst -- Healthcare Medicaid

Role: Business Analyst — CMdS Claims, Member & Finance Implementation (MES)

Location: Virgina (Remote)

Required Experience: 8+ years

Domain: Medicaid Enterprise Systems (MES) | MMIS modernization | Claims / Member / Finance

Role summary

Serve as Business Analyst for CMdS product development and implementation on a Medicaid modernization program. Translate legacy MMIS claims, member, and finance behavior and state Medicaid policy into CMdS functional design, requirements, and acceptance criteria. Partner with development, QA, architecture, and business stakeholders to deliver MES-aligned solutions that replace or integrate with legacy adjudication, eligibility/enrollment, and financial accounting processes.

Key responsibilities

Delivery & analysis

Own requirements and functional design for assigned CMdS modules (Claims, Member, Finance, and related interfaces).

Define epics, user stories, and definition of done; prioritize against Medicaid policy, MES certification goals, and release plans.

Facilitate working sessions; clarify requirements for developers and QA; resolve functional questions during build and test.

Track scope, dependencies, risks, and decisions; maintain traceability from legacy rule to CMdS design to test evidence.

Functional design (Claims, Member, Finance)

Claims: Lead functional design for claim intake, claim type assignment, validity/pricing edits, adjustment/void, crossover, encounters, remittance, and related edit disposition behavior; map legacy rules to CMdS configuration and customizations.

Member: Lead design for eligibility spans, aid category / benefit package assignment, enrollment, MCO/FFS indicators, and interfaces from state eligibility systems into CMdS Member.

Finance: Lead design for payment cycles, budget account / category of service, fund splits, ASO / F/EA and other administrative payment paths, financial transactions, and reporting/accounting controls.

Produce BRDs, FRDs, process flows, data mapping, gap analysis, and configuration workbooks suitable for build and UAT.

Collaboration with Development & QA

Work side-by-side with developers on design walkthroughs, edge cases, and defect triage.

Partner with QA to define test scenarios, expected results, and regression packs (positive/negative, adj/void, crossover, encounter, finance posting).

Support SIT, UAT, and parallel/run-compare activities against legacy MMIS outcomes.

Validate that implementations meet Medicaid policy and MES operational readiness (security, audit, reporting, interfaces).

Stakeholder & MES engagement

Run workshops with business owners, SMEs, fiscal, and operations.

Align designs to CMS MES expectations (modularity, interoperability, standards-based interfaces, certification evidence).

Support change management: training outlines, release notes, and operational runbooks for CMdS go-live.

Required qualifications

8+ years business analysis experience in Medicaid MMIS / MES, with deep hands-on work in at least two of: Claims, Member/Eligibility-Enrollment, Finance/Financial Accounting.

Proven experience developing and implementing claims systems / MMIS / MES platforms, such as Client CMdS  (Clientt Medicaid Suite), Health Enterprise, QNXT, Facets, or comparable commercial Medicaid/claims suites.

Experience modernizing or replacing legacy MMIS (COBOL/mainframe or equivalent) with a commercial Medicaid platform.

Strong Medicaid domain knowledge, including:

FFS vs managed care; capitation vs ASO / administrative services models

Claim types, media sources, edits/EOBs, adjustments/voids, Medicare crossover, encounters

Aid categories, benefit packages, eligibility spans, timely filing, TPL concepts

Provider payments, remittance advice, budget/object codes, COS, fund source / FFP concepts

CMS / state Medicaid policy drivers relevant to MES implementation and certification

Demonstrated ability to write clear functional design and acceptance criteria for complex adjudication and financial rules.

Experience working embedded with development and QA teams in Agile or hybrid SDLC.

Excellent facilitation, documentation, and stakeholder communication skills.

Preferred qualifications

Hands-on CMdS configuration or implementation (Claims, Member, Finance, Reference, Service Auth).

Familiarity with HIPAA X12 (837/835), COBA/crossover, EVV-related claim flows.

Experience supporting CMS MES certification artifacts and evidence packages.

Prior lead BA experience on multi-module MES releases.

Soft skills

Comfortable owning ambiguity when legacy rules are incomplete; drives decisions with SMEs.

Balances policy accuracy with delivery timelines.

Credible with technical teams and business executives alike.

Education

Bachelor’s degree in business, Information Systems, Health Informatics, or related field (or equivalent experience).