SME- Clinical Laboratory Fee Schedule (CLFS)

Position- SME- Clinical Laboratory Fee Schedule (CLFS)

Location- Woodlawn, MD

Type- Remote, with periodic travel to CMS

Visa- U.S. Citizen (Ability to obtain CMS Public Trust (Moderate)

Key Responsibilities

• Serve as the contract''''s authoritative interpreter of PAMA Section 216, 42 CFR Part 414 Subpart G, and CMS sub-regulatory guidance governing CLFS private payor rate reporting, applicable laboratory determination, applicable information, and the weighted median rate-setting methodology.
• Translate CMS policy decisions and rulemaking outcomes into validated business requirements, requirements traceability matrices, and acceptance criteria for development teams working under the CMS Expedited Life Cycle (XLC) framework.
• Author and maintain data validation rule sets for the CLFS submission process, including TIN-level submission integrity, HCPCS code applicability, private payor rate plausibility, volume edits, and reporting-entity-to-applicable-laboratory mappings.
• Support the CLFS data reporting cycle end-to-end: pre-reporting outreach, submission (file upload and manual entry), CFO/President certification via OTP, validation, calculation of weighted medians, publication of rates, and post-publication corrections.
• Define and review test cases covering submitter and certifier role workflows, data ingestion, edit checks, calculation outputs, and publication files; participate in code walkthroughs and validation testing.
• Provide Tier 3 escalation support for help desk inquiries from reporting entities, applicable laboratories, certifying officials, and CMS staff on complex policy and business-process questions.
• Develop and maintain CLFS sections of the User Manual, Operator Manual, training plan, and training materials, ensuring Section 508 conformance.
• Support Authority to Operate (ATO) activities, annual Security Controls Assessments, and CFACTS documentation from a business-owner perspective.
• Brief CMS leadership on data trends, submission compliance, and impacts of proposed policy changes; provide analytical support to inform Physician Fee Schedule rulemaking and other CMS proposals affecting CLFS.
• Coordinate with Medicare Administrative Contractors (MACs), CMS Shared Services (CMS Enterprise Portal, IDM/EIDM), and other stakeholders as CLFS data is consumed by downstream payment systems.

Required Qualifications

• Bachelor''''s degree in health policy, health administration, public health, life sciences, economics, or a related field.
• Minimum 7 years of progressive experience in Medicare Part B payment policy or clinical laboratory reimbursement, including at least 3 years working directly with CLFS, PAMA private payor rate reporting, or clinical lab billing operations.
• Working knowledge of HCPCS Level I (CPT) and Level II laboratory codes, the CLFS rate-setting methodology (weighted median of private payor rates), and the distinction between CDLTs and Advanced Diagnostic Laboratory Tests (ADLTs).
• Understanding of CLIA certification, the statutory “applicable laboratory” and “applicable information” definitions, the majority-of-Medicare-revenues threshold, and low-expenditure thresholds.
• Demonstrated ability to translate statute and regulation into discrete, testable system requirements.
• Experience supporting CMS or other federal contracts operating under a formal SDLC (XLC, EPLC, or equivalent).
• Familiarity with CMS Enterprise Portal, IDM (formerly EIDM), CFACTS, and CMS Acceptable Risk Safeguards (ARS).
• Strong written communication skills; able to produce policy memoranda, user-facing instructions, and engineering-grade requirements with equal clarity.

Preferred Qualifications

• Master''''s degree (MHA, MPH, MPP, or equivalent).
• Prior experience as a contractor or federal employee on a CMS payment system (CLFS, ASP, PFS, OPPS, or AFS).
• Direct experience inside a clinical laboratory''''s reimbursement, compliance, or finance function.
• Familiarity with the CY Physician Fee Schedule (PFS) rulemaking cycle and how CLFS provisions move through proposed/final rules.
• Working knowledge of Section 508 / 36 CFR Part 1194 accessibility requirements.
• Experience with statistical or actuarial review of payment rate calculations.
• Familiarity with Agile/Scrum delivery within an XLC-governed program.

Thanks & Regards

Shivam Rajpal

Team Lead- US IT Recruitment

Desk- X 106

Email- 

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