Medicaid Compliance Subject Matter Expert, SME

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

📋 Description

• Analyze Medicaid regulations, Program Integrity, Third-Party Liability (TPL), Payment Error Rate Measurement (PERM), and compliance standards pertinent to the project.

• Assist in compliance evaluations, audit preparation tasks, and the documentation of risks and deficiencies.

• Create suggestions, corrective action strategies, and process enhancements to resolve compliance issues.

• Aid in responding to inquiries from the Centers for Medicare & Medicaid Services (CMS), state agencies, or stakeholders regarding Medicaid Program Integrity and Fraud, Waste, and Abuse (FWA) activities.

• Contribute to the development and refinement of monitoring strategies, review protocols, documentation criteria, and systematic compliance review processes for Program Integrity, FWA, TPL, PERM, audit assistance, and corrective action initiatives.

• Convert compliance findings, Medicaid policy interpretations, audit outcomes, operational demands, and stakeholder feedback into actionable recommendations for process modifications, policy clarifications, system considerations, vendor follow-up, training requirements, or corrective action planning.

• Assist in maintaining documentation quality, escalating issues, tracking decisions, and ensuring follow-through for compliance, Program Integrity, audit, TPL, and FWA-related endeavors throughout the project.

• Collaborate with policy, program, analytics, forensic, payment integrity, audit, TPL, vendor, and project leadership teams to harmonize findings, prioritize follow-up actions, and coordinate recommendations.

• Evaluate policies, procedures, workflows, and operational documents for compliance-related aspects.

• Facilitate Medicaid system, policy, and operational improvement initiatives by leveraging program knowledge in workflows, documentation, stakeholder requirements, and business process redesign activities.

• Identify and track compliance, operational, and system-related risks that could influence Program Integrity, TPL, PERM, FWA, audit assistance, policy alignment, or related Medicaid operations.

• Examine the implications of federal and state Medicaid policy modifications on operations, compliance tasks, reporting, documentation, training, and system-supported workflows.

• Assist with system upgrades, testing, implementation, and validation activities when compliance, program, reporting, or operational needs intersect with Medicaid system modifications.

• Support onsite strategic planning, compliance-focused workgroup sessions, operational readiness discussions, and other project activities where expertise in Medicaid compliance, policy, or Program Integrity is required.

• Facilitate knowledge transfer, training, and preparedness activities for Medicaid personnel, project teams, or stakeholders regarding compliance obligations, process alterations, system workflows, and program integrity concepts.

⛳️ Requirements

• Proven experience with Medicaid compliance, Program Integrity, TPL, PERM, audit responses, or corrective action planning.

• Strong capabilities in policy interpretation, documentation, and risk assessment.

• Experience collaborating with operational, policy, analytical, and leadership stakeholders.

• Preferred Qualifications/Experience: Background in supporting Medicaid, health and human services, Program Integrity, TPL, PERM, audit responses, FWA, or corrective action initiatives.

• Familiarity with Vendor-managed Medicaid systems or similar public sector technology environments.

• Experience with release readiness, system upgrades, testing, implementation, validation, operational readiness, or post-implementation follow-up.

• Experience coordinating with cross-functional project teams, compliance subject matter experts (SMEs), payment integrity SMEs, audit and TPL SMEs, training, operations, policy, vendor partners, and project leadership.

• A minimum of three (3) years of experience in a comparable Medicaid compliance, program integrity, audit, or consulting position is preferred.

🏝️ Benefits

• Eligible employees have access to benefits that extend beyond the ordinary to support their physical, mental, career, social, and financial wellness.