SME

SME Onsite: Jackson, MS

Client Looking for Provide subject matter expertise related to program data, policies and operational workflows to support the Program Integrity (PI) tool used for detecting fraud, waste and abuse.

Responsibilities:

• Data Domain Expertise
• Medicaid Member Data (eligibility, enrollment, demographics, coverage)
• 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
• Claim lifecycle and adjudication
• Service codes (CPT, HCPCS, ICD, DRG)
• Payment and encounter processing
• Claim adjustments and resubmissions
• Managed Care Data
• MCO encounter data
• Capitation payments
• Managed care reporting
• Encounter-to-claim validation
• Program Integrity Support
• Fraud, waste and abuse detection support
• Data mapping and data model validation
• Development of analytics rules
• Data quality analysis and remediation
• Defining investigative use cases
• Medicaid policy interpretation
• Implementation Support
• Collaborate with vendors and system integrators
• Data ingestion and transformation support
• Data validation and reconciliation
• Requirements gathering and design sessions
• UAT support
• System output validation
• Stakeholders
• Program Integrity leadership
• Data analytics teams
• Medicaid staff
• IT architecture teams
• Implementation vendors
• Managed care oversight teams
• Work Products
• Data domain documentation validation
• Data dictionary validation
• Business rule validation
• Data quality reports
• System configuration documentation
• UAT validation reports.

Qualification: REQUIRED SKILLS (RANK IN ORDER OF IMPORTANCE): THE ABILITY TO:

• 15+ years Medicaid program data and operations
• Experience with:
• Member / Eligibility data
• Provider enrollment data
• Claims and encounter data
• Managed care data
• Experience with Gainwell MMIS
• Strong Medicaid policy knowledge
• Experience with system implementation or modernization
• Ability to communicate technical data concepts.

Preferred/Not Required:

• Provider enrollment systems
• Claims systems
• CMS reporting compliance.

About our Company:

DataSoft Technologies is a highly recognized provider of professional IT Consulting services in the US. Founded in 1994, DataSoft Technologies, Inc. provides staff augmentation services for Information Technology and Automotive Services. Our team member benefits include:

• Paid Holidays/Paid Time Off (PTO)
• Medical/Dental Insurance Group
• Accident/Critical Illness Insurance
• Life Insurance
• 401 (K)

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