Medicaid Claims Operations Consultant

Overview of job

The Medicaid Claims Operations Consultant provides coordination and support for MES existing MMIS initiatives affecting operations related to the modernization of the MMIS and planning and support for the transition to the new Claims Processing and Management Services (CPMS) and Enterprise Data Services (EDS) environment and structure.

Job Responsibilities

• Provide operational advice to the Agency for the transition to the new CPMS and ongoing for the implementation of major changes affecting MES operations.
• Focusing on readiness for claims processing, payment cycles, provider enrollments and business continuity.
• Advise program and project leadership on operational readiness, phase gate reviews, risks, and go-live considerations.
• Review and advise on MMIS change pipeline to ensure alignment with operational processes to minimize disruption.
• Work with Program Managers and Certification Lead to stay aligned and assist in getting UAT complete to prepare for a successful ORR.
• Support cross-module coordination by identifying operational dependencies and gaps impacting transition readiness.
• Support post-production certification efforts related to operations.
• Act as the primary functional liaison between the Agency, incumbent MMIS contractor, EDS contractor, and CPMS contractor on operational matters.
• Review and comment on relevant schedules and deliverables.
• Identify Risk, Issues, Action Items, and Decisions.
• Manage scope, quality, and stakeholder communication.
• Manage submission of relevant deliverables.
• Ensuring that AMMP PMO processes and procedures are followed.
• Coverage of operational documentation from the incumbent vendor to the new vendor and internal teams.
• Identify and escalate operational risks and impacts related to CPMS claims processing, vendor transition, and certification.
• Consult with the Agency and the contractors on best practices in change management, testing, quality management and architecture.
• Provide suggestions for improvements in operational efficiency and accuracy.

Basic Qualifications

• A minimum of ten (10) years of experience with medium-to-large-sized healthcare IT programs.
• A minimum of five (5) years’ recent experience in MMIS operations specifically, in Claims processing lifecycle, provider management, mailroom operation and call centers.
• Reimbursement and financial operations, with a preference for experience with Interchange.
• Demonstrated experience in system transition or platform replacement (data center to cloud) and vendor transition (incumbent to new vendor).
• Bachelor’s degree, or equivalent work experience.

Preferred Skills

• Strong understanding of MMIS claims processing and Medicaid business workflows (claims, payments, provider interactions).
• Knowledge of CMS certification expectations (OBC/SMC) and MITA framework.
• Experience in evaluating transition risks and ensuring operational readiness for large-scale system changes.
• Familiarity with cloud-based architecture and data/integration patterns in Medicaid environments.