Medicare MACs Subject Matter Expert — FFS Operations

Peraton; United States; On-site; USD 140,000 - 190,000; Full time

Job summary

Peraton is seeking a highly experienced Subject Matter Expert (SME) to support CMS operations across the Medicare Fee‑For‑Service ecosystem. The role requires deep knowledge of MACs, claims processing, and provider workflows to guide program analysis and performance evaluations.

The SME will advise on MAC relationships with RACs, UPICs, QIOs, and other contractors, ensuring alignment with CMS requirements and acquisition guidance.

Qualifications

• Minimum of 12 years with BS/BA; or 16 years of experience with a high school diploma.
• Extensive knowledge of Medicare Fee‑For‑Service 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 of MAC relationships with key functional 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 multi‑disciplinary teams.
• Ability to obtain a Public Trust clearance.
• US Citizen or Green Card Holder.

Responsibilities

• Serve as lead expert on the purpose, structure, and scope of Medicare Administrative Contractors (MACs), including A/B MACs and DME MACs, and their critical role as CMS’s primary operational interface with providers.
• Advise project teams on MAC operational responsibilities such as claims processing, payment accounting, provider enrollment, appeals (redeterminations), medical review, provider education, and the development of Local Coverage Determinations.
• Provide insight on MAC scale, claim volumes, provider populations, and Medicare FFS benefit disbursements to support Peraton’s program analysis and performance evaluations.
• Guide teams in understanding MAC relationships with key functional contractors in the Medicare FFS ecosystem, including RACs, UPICs, VDCs, QIOs, QICs, SMRCs, BCRC, CCO, and HIGLAS.
• Support project’s federal contracting and compliance activities by interpreting CMS procurement requirements, regulations, historical guidance, and the evolution of MACs under the Medicare Prescription Drug Improvement and Modernization Act.
• Partner with area project managers, analysts, and technical leads to evaluate MAC operations, identify areas for operational enhancement, and ensure alignment with CMS program goals and contractor obligations.
• Contribute subject matter expertise to solution development, proposal writing, requirements analysis, risk identification, operational playbooks, technical documentation, and customer‑facing deliverables.
• Advance Peraton’s mission by ensuring teams understand how MACs operate as the hub of Medicare FFS activities and how this affects interoperability, data flows, and program performance.

Skills

Medicare FFS knowledge

MAC operations expertise

Regulatory compliance

Stakeholder communication

Federal contracting experience

Data-driven decision making

Public Trust clearance

Education

BS/BA required

HS diploma + 16 years experience

Job description

Peraton is seeking a highly experienced Subject Matter Expert (SME) to support CMS operations across the Medicare Fee‑For‑Service ecosystem. The role requires deep knowledge of MACs, claims processing, and provider workflows to guide program analysis and performance evaluations.

The SME will advise on MAC relationships with RACs, UPICs, QIOs, and other contractors, ensuring alignment with CMS requirements and acquisition guidance.