The Medicaid Subject Matter Expert(SME)


The Medicaid Subject Matter Expert(SME) will provide support in the area of proactive data analysis used toidentify investigative targets in the Medicaid Program. The SME will performfraud, waste and abuse detection, deterrence and prevention activitiesinvolving Medicare and Medicaid providers, suppliers, and other entitiesreceiving reimbursement under one or both of the Medicare and Medicaidprograms. This includes providers,suppliers, and other entities performing under Medicare Advantage, the MedicarePrescription Drug Program (Part D), Medicaid Managed Care, and other programsadministered or operated by CMS or State Medicaid Agencies for Medicare claimsprocessed within the jurisdiction.


· Providesubject matter expertise and technical assistance on matters related toMedicaid policies and regulations.

· Identificationof proactive data studies in the Medicaid program, resulting in identificationof high ROI fraud schemes in the Medicaid program in IL, IN, IA, KS, KY, MI, MN,MO, NE, OH and WI

· Generateinvestigative leads related to trending fraud schemes

· Remaininformed of current Medicaid fraud and abuseissues/schemes through researching reports such as CMS MIG Reviews, OIG StateReports, National Association of Medicaid Directors (NAMD) Briefs and otherresources included in the Medicaid SME Research list

· Identifyand document state program vulnerabilities

· AttendMedi-Medi meetings with external customers

· Ensureconfidentiality of all PHI and sensitive information

· Travelas required for meetings or training

· Performother duties as assigned

Minimumrequired qualifications/skills:

· BA or BS degree

· Minimum of three (3) years of Medicaidexperience is required

· Experience in program integrity or medicalreview

· Excellent oral, written and verbal skills with experiencecompiling data and writing reports

· Ability to work independently with minimalsupervision in a fast-paced environment with strict deadlines

· High proficiency level with Microsoft Excel andWord

· Working knowledge of Microsoft PowerPoint

· Excellent research skills including internetresearch

· Ability to work independently with minimalsupervision

· Must have and maintain a valid drivers licenseissued by state of residence


· Certified Fraud Examiners (CFE) designationand/or Accredited Healthcare Fraud Investigator (AHFI) designation


· None


· Work from Home

OfficeEquipment (if a WFH position):

· A locking cabinet and/or desk appropriate for storingdocuments and electronic media

· A cross-cut or micro-cut (preferred) shredder

· A broadband internet connectionwith minimum download speed of 15MB – 20MB. (Wireless Air Cards are not approved forwork from home use. Free/public wi-fi connections not approved.)

· Telework office connection can be hard-wired direct orWi-Fi connection. Minimum of WPA2 (Wi-Fi Protected Access II); prefer WPA2 +AES. (WPA and WPE are not approved.) Recommended home wireless standards: WirelessG Goes through walls, but Medium speed. (Use if router not visible); WirelessN – Great for Speed, but not effective through walls. (Use if router visible); WirelessAC – High speed, but not effective through walls or distance. (Use if routervisible)

· Separate phone line (can be a cell phone)

· Office equipment (such as laptop and printerwill be provided)


· May require prolonged periods of sitting at adesk.


· Successful candidates will be required to consentto background checks, credit check and other contract related screenings

· Travel may be required, and all travel expenses, if applicable,are reimbursable via GSA standards


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