Experienced Provider+ Business Analyst - MMIS / Medicaid Pharmacy

About the role

The Experienced Provider+ Business Analyst supports business, policy, and technical execution across one or more functional domains within MMIS Medicaid Management Information Systems (MMIS) and/or the Medicaid Pharmacy environment. Supported domains may include Member, Provider, Claims (Medicaid, Dental and/or Pharmacy), Finance, Plan and Care Management, and Business Relationship Management. This role supports end-to-end domain delivery by translating state and federal Medicaid policy and program requirements into product features, system configuration, and design artifacts.

Responsibilities

• Acts as the primary Domain Subject Matter Expert (SME) and trusted advisor to the Engagement Lead (EL), providing guidance on business processes and regulatory/operational impacts.
• Ensures solution design and configuration align with CMS guidance, state policy, and documented business rules.
• Supports in-scope negotiations and change control by evaluating scope trade-offs and associated functional, regulatory, and operational impacts.
• Leads and participates in requirements and design sessions with clients and internal teams to validate business and technical needs.
• Interprets federal and state Medicaid policy, translating it into product features, system configurations, business rules, and design artifacts.
• Serves as a domain SME, supporting analysis, interpretation, and solution recommendations.
• Develops and maintains domain design documentation (including Design Documents) covering workflows, interfaces, X12 EDI transactions, letters, and reports.
• Ensures requirements and acceptance criteria are accurate, complete, and traceable.
• Documents and communicates decisions, risks, assumptions, and dependencies, including downstream impacts.
• Builds / Configuration
• Supports configuration and implementation activities across Design, Development, and Implementation (DDI).
• Pairs with technical teams to ensure alignment with approved designs, policy interpretation, and business rules.
• Configures key functional areas including: Claims: edits, pricing, benefit limits, adjudication logic, Plan: contracts, benefits, programs, fee schedules, Provider: provider types, specialties, enrollment, credentialing, Member: eligibility, demographics, benefit plans, Pharmacy: RX benefits and claims processing.
• Testing
• Reviews test cases for alignment with requirements and policy.
• Provides SME support during System Integration Testing (SIT) and User Acceptance Testing (UAT).
• Affords assistance with defect analysis, root cause investigation, resolution, retesting, and validation of functional readiness.
• Operational Readiness & Deployment
• Supports operational readiness across environments, data, processes, and staffing.
• Contributes domain expertise to Operational Readiness Reviews (ORR), parallel testing, and performance testing.
• Affords assistance with cutover planning, transition to operations, and hypercare support.
• Collaboration & Client Engagement
• Parses closely with Domain Leads, technical teams, and stakeholders as a trusted SME.
• Leads and supports client interactions, including requirements discussions, design reviews, and issue resolution.
• Plans and delivers demos and walkthroughs to validate solutions against requirements.
• Facilitates working sessions across business, configuration, and technical teams, and supports documentation, knowledge transfer, and ongoing operations.

Requirements

• Bachelor’s degree in Computer Science, Information Systems, Health Informatics, or a related field.
• 5 to 8 years of hands-on experience supporting healthcare system implementations, including MMIS solutions and Medicaid Pharmacy platforms.
• Experience with QNXT or similar healthcare claims/encounter management systems.
• Strong knowledge of state and federal Medicaid policy, regulations, and program rules (required).
• Strong understanding of Medicaid domains, including claims, member, provider, and prior authorization processes.
• Demonstrated experience translating policy and program rules into system requirements, configuration support, and design artifacts.
• Strong knowledge of SQL is required, particularly for data analysis and validation.
• Strong client communication skills, with experience interacting directly with business stakeholders.
• Proven ability to lead or support functional demonstrations, walkthroughs, and collaborative working sessions.
• Strong documentation, facilitation, and analytical skills.
• Experience working in SDLC and Agile delivery environments.

Qualifications

• Knowledge of MITA (Medicaid Information Technology Architecture).
• Experience with system integrations, EDI/X12 transactions, analytics, and reporting.
• Familiarity with state and federal healthcare regulations and compliance standards.

Skills

• Strong knowledge of state and federal Medicaid policy, regulations, and program rules.
• Strong understanding of Medicaid domains, including claims, member, provider, and prior authorization processes.
• Experience working in SDLC and Agile delivery environments.
• Strong knowledge of SQL for data analysis and validation.
• Strong client communication skills, with experience interacting directly with business stakeholders.
• Proven ability to lead or support functional demonstrations, walkthroughs, and collaborative working sessions.
• Strong documentation, facilitation, and analytical skills.
• Experience with system integrations, EDI/X12 transactions, analytics, and reporting.
• Familiarity with state and federal healthcare regulations and compliance standards.

Benefits

Gainwell Technologies offers fully remote options from Contiguous US locations only. Video cameras must be used during all interviews, as well as during the initial week of orientation. This posting is intended for pipelining. This is a developing position therefore the job description is subject to change.

Pay

The pay range for this position is $86,800 - $124,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.