Job description

Required qualifications • 12+ years business analysis experience in Medicaid MMIS / MES, with deep hands-on work in at least two of: Claims, Member/Eligibility-Enrollment, Finance/Financial Accounting. • Proven experience developing and implementing claims systems / MMIS / MES platforms, such as CMds, Health Enterprise, QNXT, Facets, or comparable commercial Medicaid/claims suites. • Experience modernizing or replacing legacy MMIS (COBOL/mainframe or equivalent) with a commercial Medicaid platform. • Strong Medicaid domain knowledge, including: • o FFS vs managed care; capitation vs ASO / administrative services models • o Claim types, media sources, edits/EOBs, adjustments/voids, Medicare crossover, encounters • o Aid categories, benefit packages, eligibility spans, timely filing, TPL concepts • o Provider payments, remittance advice, budget/object codes, COS, fund source / FFP concepts • o CMS / state Medicaid policy drivers relevant to MES implementation and certification • Demonstrated ability to write clear functional design and acceptance criteria for complex adjudication and financial rules. • Experience working embedded with development and QA teams in Agile or hybrid SDLC. • Excellent facilitation, documentation, and stakeholder communication skills. • Preferred qualifications • Hands-on CMdS configuration or implementation (Claims, Member, Finance, Reference, Service Auth). • Familiarity with HIPAA X12 (837/835), COBA/crossover, EVV-related claim flows. • Experience supporting CMS MES certification artifacts and evidence packages. • Prior lead BA experience on multi-module MES releases.

Requirements

Must-haves

12+ years business analysis experience in Medicaid MMIS / MES, with deep hands-on work in at least two of: Claims, Member/Eligibility-Enrollment, Finance/Financial Accounting.
Proven experience developing and implementing claims systems / MMIS / MES platforms, such as CMds, Health Enterprise, QNXT, Facets, or comparable commercial Medicaid/claims suites.
Experience modernizing or replacing legacy MMIS (COBOL/mainframe or equivalent) with a commercial Medicaid platform.
o FFS vs managed care; capitation vs ASO / administrative services models
o Claim types, media sources, edits/EOBs, adjustments/voids, Medicare crossover, encounters
o Aid categories, benefit packages, eligibility spans, timely filing, TPL concepts
o Provider payments, remittance advice, budget/object codes, COS, fund source / FFP concepts
o CMS / state Medicaid policy drivers relevant to MES implementation and certification
Demonstrated ability to write clear functional design and acceptance criteria for complex adjudication and financial rules.
Experience working embedded with development and QA teams in Agile or hybrid SDLC.
Excellent facilitation, documentation, and stakeholder communication skills.

Nice-to-haves

Hands-on CMdS configuration or implementation (Claims, Member, Finance, Reference, Service Auth).
Familiarity with HIPAA X12 (837/835), COBA/crossover, EVV-related claim flows.
Experience supporting CMS MES certification artifacts and evidence packages.
Prior lead BA experience on multi-module MES releases.

Application prep

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Keywords to mirror

agile

Platform: jobdiva
Effort: medium