Sr Medicaid Subject Matter Expert - CMS-64 - Federal Reporting and Policy - Remote

UnitedHealth Group; Schaumburg (IL); Remote; USD 113,000 - 193,000; Full time

Job summary

UnitedHealth Group seeks a Senior Medicaid SME to anchor the IL EDW, Medicaid policy interpretation, and CMS-64 reporting. You will translate complex policy into clear business rules, guide cross-functional teams, and briefing senior leadership on how data supports program goals.

You will work remotely from anywhere in the U.S., with occasional in-person collaboration as needed and travel to IL a few times yearly. You will mentor staff and help sustain data governance and reporting integrity.

Qualifications

• 15+ years of healthcare experience, including direct Medicaid agency/EDW exposure.
• 3+ years of experience with CMS reporting like MARS, T-MSIS, PERM, Core Set.
• Hands-on CMS-64 reporting experience including expenditure reporting and FMAP.
• Solid knowledge of Medicaid/CHIP policy and rules.
• Deep understanding of Medicaid data flows from source systems to EDW and reports.
• Ability to present to senior executives with clear briefings.
• Translate policy into business rules for technical teams.
• Proficient in SQL or similar tools for data validation.
• Willingness to travel to Springfield, IL several times a year.
• Excellent written and verbal communication.

Responsibilities

• Serve as senior Medicaid SME for IL EDW and CMS reporting.
• Lead CMS-64 and related federal reporting efforts.
• Support additional federal reporting work (MARS, T-MSIS, PERM, CMS Core Set).
• Interpret CMS/state policy into actionable business rules and requirements.
• Explain data trends and drivers to State leadership in plain terms.
• Deliver executive briefings and recommendations to Optum and State leadership.
• Collaborate with State finance, MCOs, and vendors on reporting timelines.
• Review report logic and data mappings from a business perspective.
• Identify data quality risks and propose practical fixes.
• Mentor analysts and ensure knowledge continuity.

Skills

Healthcare experience

Medicaid data

CMS reporting

CMS-64 reporting

Medicaid policy

Medicaid data flow

Executive briefing

Policy translation

SQL queries

Travel flexibility

Communication skills

Medicaid finance ops

CMS certification

Product owner SME

Illinois Medicaid

BI tools (Tableau/Power BI)

Project tools (Azure DevOps/JIRA)

CMS reporting systems

Location IL commuting

Tools

SQL

Job description

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together.

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.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

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

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

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
• 3+ years of experience with other federal CMS reporting such as MARS, T-MSIS, PERM, or CMS Core Set measures
• Hands-on experience supporting CMS-64 reporting, including expenditure reporting, FMAP/enhanced match, claiming categories, and reconciliation of data to financial reports
• Solid 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
• Provenability to translate policy and federal guidance into business rules and requirements that technical teams can build and test
• Provenworking ability to query and validate data using SQL or similar tools against large datasets
• Provenability to travel to Springfield, IL three (3) to four (4) times per year or as needed
• Provenexcellent written and verbal communication, sound judgment, and the ability to stay calm and credible in high-visibility, deadline-driven situations

Note: Core customer business hours are M-F 8 AM to 5 PM CST

Preferred Qualifications

• Experience with State Medicaid finance operations, CMS-64 quarterly cycles, CMS-37 budget reporting, or federal draw and claiming processes
• 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
• 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
• Familiarity with CMS federal financial reporting systems (MBES/CBES) and the transition to MACFin
• Located within driving distance of Springfield, IL

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $112,700 - $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives.

UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.