Medicaid Subject Matter Expert

Position Overview The Medicaid Subject Matter Expert (SME) will provide deep expertise in Medicaid program data, policies, and operational workflows to support the implementation and operationalization of a Program Integrity (PI) solution. The SME will collaborate with technical teams, program staff, vendors, and project leadership to ensure the system effectively leverages Medicaid data to detect, prevent, and investigate fraud, waste, and abuse. Key Responsibilities Data Domain Expertise Provide expert guidance across key 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) integration Claims Data • Professional, institutional, and pharmacy claims • Claims lifecycle and adjudication processes • Service coding systems (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 • Provide expertise on fraud, waste, and abuse detection strategies • Assist with data mapping and validation for the Program Integrity tool • Support development of analytics rules and investigative workflows • Identify data quality issues and remediation strategies • Define use cases and investigative scenarios • Ensure accurate interpretation of Medicaid policies and program rules Implementation Support • Collaborate with system integrators and vendors • Support data ingestion, transformation, and validation • Participate in requirements gathering and design sessions • Provide business context for technical teams • Review system outputs for accuracy and relevance • Support User Acceptance Testing (UAT) Stakeholder Collaboration Work closely with: • Program Integrity leadership • Medicaid program staff • Data analytics teams • IT and data architecture teams • Implementation vendors • Managed Care oversight teams Work Products The SME will contribute to the development and validation of: • Medicaid data domain documentation • Data mapping and data dictionary validation • Program Integrity business rules and use cases • Data quality assessments and recommendations • System configuration validation documentation • UAT validation reports • Implementation support findings • Required Qualifications • 15+ years of experience working with Medicaid program data and operations • 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 MMIS or successor Medicaid systems • Strong understanding of Medicaid policies and regulatory requirements • Experience supporting large system implementations or modernization initiatives • Ability to communicate complex Medicaid data concepts to both • technical and non-technical stakeholders Preferred Qualifications • Experience implementing Provider Enrollment systems • Experience implementing Medicaid claims systems • Experience working with claims data management