Medicare MACs SME | Strategic Ops & Policy Expert

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

Job summary

Peraton in Herndon, VA, seeks a senior Subject Matter Expert (SME) specializing in Medicare Administrative Contractors (MACs) to support CMS operations across the Medicare FFS ecosystem.

You will advise project teams on MAC responsibilities, guide procurement and compliance, and help improve operational performance by sharing authoritative knowledge of MAC structures and CMS regulations. This role requires US citizenship or a Green Card and the ability to obtain a Public Trust clearance.

Qualifications

• Minimum 12 years with BS/BA; or 16 years with a high school diploma.
• Extensive knowledge of Medicare FFS program operations and CMS contractor structures.
• Experience with all claim types: Part A, Part B, Home Health & Hospice, Railroad Board, DME
• Expertise in claims adjudication, provider enrollment workflows, appeals processes, medical review, and coverage determination development.
• Experience with Medicare Claims Pricing, CMS Web Pricer, Prospective Payment Systems and Fee Schedules
• Demonstrated experience working with or supporting CMS, Medicare contractors, or large federal health programs.
• Understanding MAC relationships with key contractors across the FFS landscape (RACs, UPICs, QIOs, QICs, VDCs, SMRCs, etc.).
• Understanding of edits used by MACs and working suspense codes.
• Understanding of reporting needs/uses from claims systems.
• Understanding of Provider and/or Bene workflows for claims processing and payments.
• Strong familiarity with CMS regulations, guidance, and acquisition requirements.
• Proven ability to communicate complex program information to diverse stakeholders including federal customers, program managers, and multidisciplinary teams.
• Ability to obtain a Public Trust clearance.
• US Citizen or Green Card Holder.

Responsibilities

• Serve as SME on MACs' purpose, structure, and scope across CMS interface with providers.
• Advise on MAC operational responsibilities such as claims processing, enrollment, appeals, medical review, and LD determinations.
• Provide insight on MAC scale, claim volumes, provider populations, and FFS benefit disbursements.
• Guide teams on MAC relationships with RACs, UPICs, QIOs, QICs, VDCs, SMRCs, etc.
• Support contracting and compliance by interpreting CMS procurement requirements and MAC evolution.
• Partner with project managers and analysts to evaluate MAC operations and drive improvements.
• Contribute to solution development, proposals, requirements analysis, risk, and customer-facing deliverables.
• Advance Peraton's mission by clarifying MAC operation's impact on data flows and program performance.

Skills

Medicare FFS operations

CMS contractor structures

Claims adjudication

Provider enrollment workflows

Appeals processes

Medical review

CMS regulations

Stakeholder communication

MAC relationships

Education

BS/BA degree

High school diploma

Tools

CMS Web Pricer

Medicare Claims Pricing

Prospective Payment Systems

Fee Schedules

Job description

Peraton in Herndon, VA, seeks a senior Subject Matter Expert (SME) specializing in Medicare Administrative Contractors (MACs) to support CMS operations across the Medicare FFS ecosystem.

You will advise project teams on MAC responsibilities, guide procurement and compliance, and help improve operational performance by sharing authoritative knowledge of MAC structures and CMS regulations. This role requires US citizenship or a Green Card and the ability to obtain a Public Trust clearance.