Data Processing Subject Matter Expert (DP SME)
The Data Processing Subject Matter Expert (DP SME) will play a pivotal role in providing technical direction, guidance, and expertise to the data processing team, collaborating closely with the DP Manager, DP Assistant Review Manager, DP Reviewers, and CMS PERM staff. This individual will offer specialized knowledge in claims processing systems and procedures, contributing to the review, research, and investigation of claims while ensuring compliance with federal and state regulations.
Responsibilities:

• Collaborate with the DP Manager, DP Assistant Review Manager, and DP Reviewers to offer technical guidance and direction to the data processing team.
• Provide expertise and support in reviewing, researching, and investigating claims processing systems and processes.
• Offer guidance on state compliance regarding federal and state regulations and policies.
• Provide technical assistance in all aspects of Medicaid and CHIP, emphasizing program integrity.
• Advise on managed care claims, third-party liability, Medicaid waiver programs, and provider enrollment.
• Analyze and work with states' claims processing systems, including MMIS, payment policy, systems, coding, billing, and compliance rules in Medicaid and CHIP.
• Assess compliance with state and federal laws, policies, rules, and regulations.

Qualifications:

• Minimum of three (3) years of supervisory or managerial experience in medical claims or clinical data management.
• Minimum of five (5) years working in Medicaid and/or CHIP, providing technical assistance in various facets, including program integrity.
• Extensive knowledge and practical experience in managed care claims, third-party liability, Medicaid waiver programs, and provider enrollment.
• Proficiency in state claims processing systems (including MMIS), payment policy, coding, billing, and compliance rules in Medicaid and CHIP.
• Strong understanding and expertise in determining compliance with state and federal laws, policies, rules, and regulations.
• Holds a Bachelor's degree from an accredited university in a relevant field of study.

The Data Processing Subject Matter Expert will need exceptional communication skills, critical thinking abilities, and a deep understanding of claims processing systems to ensure accurate guidance and compliance adherence. This role is integral to maintaining the efficiency, accuracy, and compliance of claims processing within the organization. This is a remote, work from home position. You may be located anywhere within the US.