EDW Medicaid SME; Federal Policy & Reporting

Clover Consulting has a direct client in Springfield, IL in need of anEDW Medicaid SME (Federal Reporting & Policy) for a 12+ months contract. Job details are below. Thank you!

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.

This SME will work alongside the existing Medicaid SME and data specialist team to build depth and continuity across Medicaid policy, federal reporting, and EDW data. The role brings credibility with State program, finance, and executive staff, and will regularly brief senior leadership up to the Agency Director level.

• 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.

• 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.
• Hands-on experience supporting CMS-64 reporting, including expenditure reporting, FMAP/enhanced match, claiming categories, and reconciliation of data to financial reports.
• 3+ years of experience with other federal CMS reporting such as MARS, T-MSIS, PERM, or CMS Core Set measures.
• Strong 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 executives, including State agency directors or equivalent, with clear and concise briefings.
• Ability to translate policy and federal guidance into business rules and requirements that technical teams can build and test.
• Working ability to query and validate data using SQL or similar tools against large datasets.
• Excellent written and verbal communication, sound…