EDW Medicaid SME (36025)

Myticas Consulting; Illinois; Remote; USD 83,000 - 99,000; Part time

Job summary

Clover Consulting is seeking an EDW Medicaid SME (Federal Reporting & Policy) for a 12+ month contract. The role is remote with occasional travel to Illinois possible, focused on CMS-64 and related federal reporting.

You will anchor Medicaid policy knowledge and translate it into actionable business rules for data and reporting teams. The candidate will brief senior leadership, work with state programs and vendors, and ensure data quality and compliance across reporting cycles.

Qualifications

• 15+ years healthcare experience including 10+ years with State Medicaid agencies or Medicaid data programs.
• 10+ years CMS reporting experience with CMS guidance and federal requirements.
• 3+ years experience with CMS reporting such as MARS, T-MSIS, PERM, or CMS Core Set measures.
• Strong knowledge of Medicaid policy, eligibility groups, waivers, TPL, and claims adjudication.
• Able to translate policy into business rules and testable requirements.

Responsibilities

• Serve as a senior Medicaid SME for the IL EDW, guiding State and Optum teams on claims, eligibility, provider, managed care, TPL, and financial data.
• Lead CMS-64 reporting support, including expenditure categories, FMAP, reporting periods, and reconciliation to financial submissions.
• Support federal reporting work (MARS, T-MSIS, PERM, CMS Core Set) ensuring alignment with source data and guidance.
• Translate CMS guidance into clear business rules for technical teams to implement and test.
• Prepare executive briefings, issue summaries, and recommendations for senior leadership.

Skills

Medicaid policy

CMS reporting

SQL querying

Executive briefs

Data validation

Stakeholder communication

Tools

Teradata

Tableau

Power BI

Azure DevOps

JIRA

Job description

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

Role

EDW Medicaid SME (Federal Reporting & Policy)

Location

Remote - occasional travel to Illinois possible

Term

12+ months contract, extensions possible

Rate

$60 W2 - $72 C2C

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.

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.

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.

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.
• 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 judgment, and the ability to stay calm and credible in high-visibility, deadline-driven situations.
• Ability to travel to Springfield, IL three (3) to four (4) times per year or as needed.

Preferred Qualifications

• Experience with State Medicaid finance operations, CMS-64 quarterly cycles, CMS-37 budget reporting, or federal draw and claiming processes.
• Familiarity with CMS federal financial reporting systems (MBES/CBES) and the transition to MACFin.
• Experience supporting MMIS/MES CMS certification, audits, or federal reviews.
• Product owner or lead SME experience for a federal reporting module or Medicaid DSS/data warehouse.
• Prior experience with Illinois Medicaid programs, or Medicaid managed care.
• Experience with Teradata, Business Objects, Tableau, Power BI, or similar reporting and data tools.
• Experience using Azure DevOps, JIRA, or similar tools, and SharePoint for documentation and collaboration.

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