Medicare MAC SME: FFS Policy & Ops Expert

Peraton; Reston (VA); On-site; USD 146,000 - 234,000; Full time

Job summary

Peraton in Reston, VA seeks a Senior SME specializing in Medicare Administrative Contractors (MACs) to support CMS operations within the Medicare FFS ecosystem. You will be the authoritative resource on MAC functions, regulations, and CMS interfaces.

Responsibilities include advising on MAC claims processing, enrollment, appeals, medical review, and coverage determinations; guiding teams on MAC relationships with RACs, UPICs, and QIOs; and ensuring compliance with CMS procurement guidance.

Qualifications

• 12+ years of Medicare FFS operations knowledge with a BS/BA.
• Extensive knowledge of Medicare FFS program operations and CMS contractor structures.
• Experience with all claim types: Part A, Part B, Home Health & Hospice, DME.
• Expertise in claims adjudication, provider enrollment workflows, appeals processes, medical review, and coverage determination development.
• Experience with Medicare Claims Pricing, CMS Web Pricer, and PPS/Fee Schedules.
• Ability to communicate complex program information to diverse stakeholders including federal customers, program managers, and multidisciplinary teams.

Responsibilities

• Serve as lead SME on MACs, including MAC structure and CMS interfaces.
• Advise project teams on MAC operational responsibilities such as claims processing, payment accounting, provider enrollment, appeals, medical review, and local determinations.
• Provide insight on MAC scale, claim volumes, provider populations, and Medicare FFS benefit disbursements for program analysis.
• Guide teams on MAC relationships with key functional contractors (RACs, UPICs, VDCs, QIOs, QICs, SMRCs, BCRC, CCO, HIGLAS).
• Support contracting and compliance activities by interpreting CMS procurement requirements and MAC evolution under relevant acts.
• Partner with project managers to evaluate MAC operations and identify areas for operational enhancement.
• Contribute SME input to solution development, proposals, requirements analysis, risk identification, operational playbooks, and documentation.
• Advance Peraton's mission by clarifying MAC operations' impact on interoperability, data flows, and program performance.

Skills

Medicare FFS knowledge

CMS contractor experience

Claims adjudication

Provider enrollment

Regulatory understanding

Stakeholder communication

Public Trust clearance

Education

BS/BA degree

Tools

CMS Web Pricer

Job description

Peraton in Reston, VA seeks a Senior SME specializing in Medicare Administrative Contractors (MACs) to support CMS operations within the Medicare FFS ecosystem. You will be the authoritative resource on MAC functions, regulations, and CMS interfaces.

Responsibilities include advising on MAC claims processing, enrollment, appeals, medical review, and coverage determinations; guiding teams on MAC relationships with RACs, UPICs, and QIOs; and ensuring compliance with CMS procurement guidance.