EDW Sr Medicaid Subject Matter Expert- Remote
Fully Remote - US
EDW Sr Medicaid Subject Matter Expert- Remote
Full Time • Fully Remote - US
Primary Responsibilities
• Serve as a senior Medicaid business and policy SME for the EDW, guiding State and project teams on claims, eligibility, provider, managed care/encounter, TPL, and financial data and how they relate to Medicaid program rules.
• Lead the business side of CMS-64 reporting support, including understanding expenditure categories, FMAP and enhanced match rules, reporting periods, prior period adjustments, and reconciliation of EDW data to State financial submissions.
• Support other federal reporting work such as MARS, T-MSIS, PERM, and CMS Core Set/Quality of Care measures, making sure reports tie back to source data and federal guidance.
• Interpret federal and State policy (CMS guidance, SMD/SHO letters, the State Medicaid Manual, the State Plan and waivers, and State administrative rules) and translate it into clear business rules, requirements, and acceptance criteria.
• Explain the "why" behind the numbers. Help State users and leadership understand trends, variances, and data issues in plain business terms, along with the policy or operational drivers behind them.
• Prepare and deliver executive briefings, issue summaries, and recommendations to project leadership and State senior leadership, including Bureau Chiefs, Deputy Administrators, and the Agency Director.
• Work with State finance and program teams (including the Bureau of Fiscal Operations), MCO partners, and other vendors on joint reporting timelines, dependencies, and approvals.
• Review and validate report logic, data mappings, and test results from a business and policy standpoint before deliverables go to the State or CMS.
• Identify data quality and reporting risks early, and recommend practical options to resolve them.
• Mentor analysts, developers, and data specialists on Medicaid business knowledge, and help build documented knowledge and backup coverage so no single person is a point of failure.
• Stay current on federal and State Medicaid changes (CMS rules, legislative mandates, federal reporting system changes) and advise the team and the State on impacts to the EDW and reporting.
Required Qualifications
• 15+ years of healthcare experience, including 10+ years working directly with or for State Medicaid agencies, MMIS/MES vendors, or Medicaid data warehouse/decision support programs.
• Hands-on experience supporting CMS-64 reporting, including expenditure reporting, FMAP/enhanced match, claiming categories, and reconciliation of data to financial reports.
• 3+ years of experience with other federal CMS reporting such as MARS, T-MSIS, PERM, or CMS Core Set measures.
• Strong working knowledge of Medicaid and CHIP policy and program rules, including eligibility groups, benefits and covered services, managed care, waivers, TPL, and claims adjudication.
• Serve as a senior Medicaid business and policy SME for the EDW, guiding State and project teams on claims, eligibility, provider, managed care/encounter, TPL, and financial data and how they relate to Medicaid program rules.
• Lead the business side of CMS-64 reporting support, including understanding expenditure categories, FMAP and enhanced match rules, reporting periods, prior period adjustments, and reconciliation of EDW data to State financial submissions.
• Support other federal reporting work such as MARS, T-MSIS, PERM, and CMS Core Set/Quality of Care measures, making sure reports tie back to source data and federal guidance.
• Interpret federal and State policy (CMS guidance, SMD/SHO letters, the State Medicaid Manual, the State Plan and waivers, and State administrative rules) and translate it into clear business rules, requirements, and acceptance criteria.
• Explain the "why" behind the numbers. Help State users and leadership understand trends, variances, and data issues in plain business terms, along with the policy or operational drivers behind them.
• Prepare and deliver executive briefings, issue summaries, and recommendations to project leadership and State senior leadership, including Bureau Chiefs, Deputy Administrators, and the Agency Director.
• Work with State finance and program teams (including the Bureau of Fiscal Operations), MCO partners, and other vendors on joint reporting timelines, dependencies, and approvals.
• Review and validate report logic, data mappings, and test results from a business and policy standpoint before deliverables go to the State or CMS.
• Identify data quality and reporting risks early, and recommend practical options to resolve them.
• Mentor analysts, developers, and data specialists on Medicaid business knowledge, and help build documented knowledge and backup coverage so no single person is a point of failure.
• Stay current on federal and State Medicaid changes (CMS rules, legislative mandates, federal reporting system changes) and advise the team and the State on impacts to the EDW and reporting.
Required Qualifications
• 15+ years of healthcare experience, including 10+ years working directly with or for State Medicaid agencies, MMIS/MES vendors, or Medicaid data warehouse/decision support programs.
• Hands-on experience supporting CMS-64 reporting, including expenditure reporting, FMAP/enhanced match, claiming categories, and reconciliation of data to financial reports.
• 3+ years of experience with other federal CMS reporting such as MARS, T-MSIS, PERM, or CMS Core Set measures.
• Strong working knowledge of Medicaid and CHIP policy and program rules, including eligibility groups, benefits and covered services, managed care, waivers, TPL, and claims adjudication.
This is a remote position.
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
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