Business Analyst – CMdS Claims, Member & Finance Implementation

This is a fully remote position, open to applicants in United States.

📋 Description

• Take responsibility for the requirements and functional design related to CMdS Claims, Member, Finance, and associated interface modules.

• Establish epics, user stories, definitions of done, and priorities that align with Medicaid policy, MES certification objectives, and release schedules.

• Conduct working sessions and provide clarification on requirements for development and quality assurance.

• Address functional inquiries during the build and testing phases.

• Monitor scope, dependencies, risks, decisions, and traceability from legacy rules through CMdS design to testing evidence.

• Direct the functional design for claims intake, various claim types, edits, adjustments, voids, crossovers, encounters, remittance, and edit disposition.

• Oversee the design for eligibility spans, aid categories, benefit packages, enrollment, MCO/FFS indicators, and eligibility-system interfaces.

• Manage the design for payment cycles, budget accounts, service categories, fund splits, administrative payment paths, financial transactions, and reporting/accounting controls.

• Create BRDs, FRDs, process flows, data mappings, gap analyses, and configuration workbooks for build and UAT processes.

• Facilitate design walkthroughs, address edge cases, and assist in defect triage alongside developers.

• Collaborate with QA on test scenarios, anticipated results, and regression test packs.

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

• Validate Medicaid policy and MES operational readiness, including aspects like security, audit, reporting, and interfaces.

• Conduct workshops with business owners, SMEs, fiscal, and operational stakeholders.

• Ensure designs are in line with CMS MES expectations for modularity, interoperability, standards-based interfaces, and certification evidence.

• Assist in change management through the development of training outlines, release notes, and operational runbooks for go-live.

⛳️ Requirements

• A minimum of 12 years of business analysis experience in Medicaid MMIS/MES.

• Extensive hands-on experience in at least two areas: Claims, Member/Eligibility-Enrollment, and Finance/Financial Accounting.

• Experience in modernizing or replacing legacy MMIS systems utilizing COBOL/mainframe or similar with a commercial Medicaid platform.

• Strong knowledge of the Medicaid domain, including FFS versus managed care, capitation, ASO, and administrative services models.

• Understanding of claim types, media sources, edits/EOBs, adjustments/voids, Medicare crossover, and encounters.

• Familiarity with aid categories, benefit packages, eligibility spans, timely filing, and TPL concepts.

• Knowledge of provider payments, remittance advice, budget/object codes, COS, fund sources, and FFP concepts.

• Awareness of CMS and state Medicaid policy drivers pertinent to MES implementation and certification.

• Capability to draft clear functional designs and acceptance criteria for complex adjudication and financial rules.

• Experience collaborating with development and QA teams in Agile or hybrid SDLC environments.

• Exceptional facilitation, documentation, and communication skills with stakeholders.

• Practical experience with CMdS configuration or implementation is preferred.

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

• Experience in supporting CMS MES certification artifacts and evidence packages is preferred.

• Previous lead BA experience on multi-module MES releases is preferred.

• Comfort with managing ambiguity when legacy rules are incomplete and making decisions with SMEs.

• Ability to balance policy accuracy with delivery timelines.

• Established credibility with technical teams and business executives.

• Willingness to travel within the United States.

• Work authorization and current location must be provided on the application.

🏝️ Benefits

• Competitive salary and performance-based bonuses.

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with company match.

• Opportunities for professional development and training.

• Flexible work hours and remote work options.