Senior Business Analyst - Medicaid Pharmacy; MMIS

Senior Business Analyst – Medicaid Pharmacy (MMIS)

Location:

Any city, IL, US, 99999 | Any city, TX, US, 99999

Work Mode:
Virtual (Exception only)

• Ensures compliance alignment by validating that solution design and configuration conform to CMS guidance, state policy, and documented business rules
  .
• Supports the EL with in‑scope negotiations and change control
  , providing domain expertise to assess scope trade‑offs and the functional, regulatory, and operational impacts of change requests.
• Lead and participate in collaborative requirements and design sessions with clients and internal teams to validate functional and technical needs.
• Interpret state and federal Medicaid policy, regulations, and program rules and translate them into product features, system configuration, business rules, and design artifacts.
• Support the Domain Lead with analysis, interpretation, and solution recommendations.
• Develop and maintain domain design documentation, with the Design Document as a core deliverable, covering workflows, interfaces, X12 EDI transactions, letters, and reports.
• Ensure accuracy, completeness, and traceability of requirements and acceptance criteria.
• Document and communicate domain‑level decisions, risks, assumptions, and dependencies, assessing downstream impacts.

• Support domain‑specific configuration and implementation activities within Design, Development, and Implementation (DDI) projects.
• Responsible for configuration and partner with technical teams to ensure solutions align with approved design documentation, Medicaid policy interpretation, and documented business rules. Key configurations include but not limited to:
  • Claims:
    Edits, pricing, benefit limits,, adjudication logic
  • Plan:
    Contracts, benefits, programs, fee schedules
  • Provider:
    Provider types, specialties, contracts, enrollment, credentialing
  • Member:
    Eligibility, benefits, benefit plans, demographic
  • Pharmacy: RX benefits, RX claims processing

• Review test cases to ensure alignment with requirements, policy interpretation, and acceptance criteria.
• Provide domain SME support during System Integration Testing (SIT) and User Acceptance Testing (UAT).
• Support defect analysis, root‑cause investigation, resolution, retesting, and functional readiness validation.

• Support operational readiness activities, including environment, data, process, and staffing readiness.
• Provide domain and policy input for Operational Readiness Reviews (ORR), parallel testing, and performance testing.
• Support cutover preparation, transition to operations, and hypercare activities.
• Work closely with the Domain Lead and Technical Analysts
  , acting as a trusted domain and policy SME.
• Lead and support client communication
  , including requirement discussions, design reviews, and issue resolution.
• Plan and deliver functional demos and solution walkthroughs to showcase product features and validate alignment with client requirements.
• Facilitate and participate in collaborative working sessions with business stakeholders, configuration teams, and technical teams.
• Support documentation, knowledge transfer, and ongoing operational support.

• Bachelor’s degree in Computer Science, Information Systems, Health Informatics, or a related field.
• 5 to 8 years of hands‑on experience supporting healthcare system implementations, including MMIS solutions and Medicaid Pharmacy platforms.
• Experience with QNXT or similar healthcare claims/encounter management systems.
• Strong knowledge of state and federal Medicaid policy, regulations, and program rules (required).
• Strong understanding of Medicaid domains, including claims, member, provider, and prior authorization processes.
• Demonstrated experience translating policy and program rules into system requirements, configuration support, and design artifacts.
• Strong knowledge of SQL is required, particularly for data analysis and validation.
• Strong client communication skills, with experience interacting directly with business stakeholders.
• Proven ability to lead or support functional demonstrations, walkthroughs, and collaborative working sessions.
• Strong documentation, facilitation, and…