Sr Medicaid Subject Matter Expert - CMS-- Federal Reporting and Policy - Remote

Position: Sr Medicaid Subject Matter Expert - CMS-64 - Federal Reporting and Policy - Remote

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives?

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Position Summary

This senior Medicaid SME supports the State Medicaid Agency Enterprise Data Warehouse (EDW). The role is the business and policy anchor for Medicaid data and federal reporting, with a primary focus on CMS-64 and related financial and federal reporting. The person in this role understands not only what the data says, but why the business works the way it does: the Medicaid policy, program rules, and federal requirements behind each claim, eligibility record, and report line.

You’ll enjoy the flexibility to work remotely
* from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities

• Serve as a senior Medicaid business and policy SME for the IL EDW, guiding State and Optum teams on claims, eligibility, provider, managed care/encounter, TPL, and financial data and how they relate to Medicaid program rules
• Lead the business side of CMS-64 reporting support, including understanding expenditure categories, FMAP and enhanced match rules, reporting periods, prior period adjustments, and reconciliation of EDW data to State financial submissions
• Support other federal reporting work such as MARS, T-MSIS, PERM, and CMS Core Set/Quality of Care measures, making sure reports tie back to source data and federal guidance
• Interpret federal and State policy (CMS guidance, SMD/SHO letters, the State Medicaid Manual, the State Plan and waivers, and State administrative rules) and translate it into clear business rules, requirements, and acceptance criteria
• Explain the "why" behind the numbers Help State users and leadership understand trends, variances, and data issues in plain business terms, along with the policy or operational drivers behind them
• Prepare and deliver executive briefings, issue summaries, and recommendations to Optum leadership and State senior leadership, including Bureau Chiefs, Deputy Administrators, and the Agency Director
• Work with State finance and program teams (including the Bureau of Fiscal Operations), MCO partners, and other vendors on joint reporting timelines, dependencies, and approvals
• Review and validate report logic, data mappings, and test results from a business and policy standpoint before deliverables go to the State or CMS
• Identify data quality and reporting risks early, and recommend practical options to resolve them
• Mentor analysts, developers, and data specialists on Medicaid business knowledge, and help build documented knowledge and backup coverage so no single person is a point of failure
• Stay current on federal and State Medicaid changes (CMS rules, legislative mandates, federal reporting system changes) and advise the team and the State on impacts to the EDW and reporting

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications

• 15+ years of healthcare experience, including 10+ years working directly with or for State Medicaid agencies, MMIS/MES vendors, or Medicaid data warehouse/decision support programs
• 3+ years of experience with other federal CMS reporting such as MARS, T-MSIS, PERM, or CMS Core Set measures
• Hands-on experience supporting CMS-64 reporting, including expenditure reporting, FMAP/enhanced match, claiming categories, and reconciliation of data to financial reports
• Solid working knowledge of Medicaid and CHIP policy and program rules, including eligibility groups, benefits and covered services, managed care, waivers, TPL, and claims adjudication
• Deep understanding of Medicaid data (claims, encounters, eligibility, provider, financial) and how it flows from source systems into a data warehouse and federal reports
• Proven ability to present to and advise senior…