Medicaid Program Integrity Subject Matter Expert (Ref #: 1118107)

Estrada Consulting, Inc.; Maryland; Remote; USD 83,000 - 110,000; Part time

Job summary

Estrada Consulting, Inc. is seeking a Medicaid program integrity subject matter expert for a part-time advisory role on a state data analytics engagement.

You will help the analytics team interpret claims and program data, define the rules behind analyses, and review significant findings with State staff before any action is taken. The project involves a cloud-based data analytics capability for a state Medicaid-funded developmental disabilities program.

Qualifications

• 1–2 years or more working in healthcare, Medicaid or other health and human services programs
• Knowledge of program operations, claims and utilization data, provider services, financial oversight or program integrity
• Able to explain program rules and data in plain language to analysts and State reviewers
• US based and able to pass a background check before access to protected health data

Responsibilities

• Interpret program rules, waiver requirements, claims and utilization data for the analytics team.
• Help define, validate and document rules-based checks and indicators.
• Review significant analytical findings with State subject matter experts before recommended actions are taken.
• Identify patterns, risks and opportunities for program and operational improvement.
• Join periodic workstream reviews and contribute to documentation and knowledge transfer.

Skills

Interpret program rules

Explain data to analysts

Communicate with State reviewers

Identify patterns and risks

Data interpretation

Education

Bachelor's degree in public health, healthcare administration, health informatics, public administration or related field

Job description

Medicaid Program Integrity Subject Matter Expert

Estrada Consulting, Inc. | Public sector health and human services client | Remote, US based | $60 to $80 per hour, part time

About the role

ECI is looking for a Medicaid subject matter expert for a part-time advisory role on a state data analytics engagement. You will help the analytics team interpret claims and program data correctly, define the rules behind each analysis, and review significant findings with State staff before any action is taken.

About the project

Estrada Consulting, Inc. (ECI) is assembling the team for a cloud-based data analytics capability for a state Medicaid-funded developmental disabilities program. The program holds claims, electronic visit verification, eligibility, provider, service plan and self-directed services fiscal data, and needs an integrated, explainable way to identify anomalies, emerging financial risk and opportunities for program improvement. The capability uses three tiers of analysis (rules-based checks, statistical comparison and relationship analysis), and every result is reviewed by State staff before any action. ECI has already built a working prototype on synthetic data.

Responsibilities

• Interpret program rules, waiver requirements, claims and utilization data for the analytics team.
• Help define, validate and document rules-based checks and indicators.
• Review significant analytical findings with State subject matter experts before recommended actions are taken.
• Identify patterns, risks and opportunities for program and operational improvement.
• Join periodic workstream reviews and contribute to documentation and knowledge transfer.

Required qualifications

• One to two years or more working in healthcare, Medicaid or other health and human services programs
• Knowledge of program operations, claims and utilization data, provider services, financial oversight or program integrity
• Able to explain program rules and data in plain language to analysts and State reviewers
• US based and able to pass a background check before access to protected health data

Preferred qualifications

• Medicaid home and community-based services (HCBS) waiver or developmental disabilities program experience
• Program integrity, audit, utilization review or fraud, waste and abuse experience
• Electronic visit verification or self-directed services experience
• Bachelor's degree in public health, healthcare administration, health informatics, public administration or a related field
• Healthcare, Medicaid or healthcare quality certification

Terms

Estimated effort: About 120 hours over a one-year contract, a few hours per week, as needed.

Work arrangement: Remote. All team members must be US based. Work follows the client's business hours, 8:00 AM to 5:00 PM Eastern, with regular video meetings on Eastern time and occasional on-site visits if the client asks.

Duration: One year, contingent on contract award. The expected start is the first quarter of 2027.

Rate: $60 to $80 per hour, depending on experience.

Other requirements: Candidates must pass the client's background check and sign confidentiality and HIPAA agreements before access to program data. The candidate's name and resume will be included in ECI's proposal, and the candidate signs a letter of intended commitment.