Medicaid Policy SME

About Us:

eSimplicity is a modern digital services company that partners with government agencies to improve the lives and protect the well-being of all Americans, from veterans and service members to children, families, and seniors. Our engineers, designers, and strategists cut through complexity to create intuitive products and services that equip federal agencies with solutions to courageously transform today for a better tomorrow.

Purpose and Scope: 

The Medicaid Policy SME shall perform the following services for eSimplicity and/or its client:

Data Analysis & Architecture Consulting

•  Provide data analysis, recommendations, and consulting on T-MSIS cloud architecture, infrastructure, and file processing to ingest Medicaid Health Data.

•  Support the creation of algorithms for critical key business processes.

•  Assist in product creation, support, and maintenance across the T-MSIS program.

•  Apply deep understanding of data elements, linkages, and downstream analytics uses across the full T-MSIS landscape to support architecture decisions and data pipeline design.

Data Quality & Business Rules

•  Create, review, and update business rules and data quality (DQ) measures for the T-MSIS program.

•  Suggest new data quality edits that validate T-MSIS claim/encounter data feeds as a Medicaid and CHIP data and policy expert.

•  Determine potential causes of failed data quality checks, including root causes tied to upstream MES system configurations, workflow design, and policy decisions.

•  Help mature processes for metadata, lineage, reconciliation, and auditability across the T-MSIS lifecycle.

•  Support data validation and anomaly resolution by translating operational Medicaid realities into clean, defensible data for CMS review.

State Technical Assistance & Engagement

•  Provide guidance to states on improvements to Medicaid Health IT data quality to support data analytics.

•  Provide direct technical assistance to states to help them remediate data issues, leveraging established relationships and credibility within state Medicaid agencies.

•  Assist in creating training materials and conducting error-focused coaching sessions for state partners.

•  Serve as a bridge between CMS, state Medicaid programs, and technical teams — translating Medicaid operational realities into actionable requirements and data improvements.

•  Understand and provide guidance on how state Medicaid programs across key MES domains including provider enrollment, member eligibility, claims adjudication, encounters, prior authorization (PA), TPL, financial management, and program integrity work.

CMS Certification & Compliance Support

•  Anticipate certification and reporting impacts by applying knowledge of CMS review standards and federal expectations for T-MSIS data and modular certifications.

•  Consult on improving the overall security posture of the T-MSIS application.

•  Perform documentation, data analysis, policy review, and support of technical implementations on the T-MSIS program.

•  Provide CMS-ready documentation with disciplined governance and traceability to support compliance reviews and audits.

Program Management & Strategy

•  Support development and execution of Objectives and Key Results (OKRs) for the T-MSIS program.

•  Provide knowledge and expertise in the data, processes, and analytics of T-MSIS data to the T-MSIS team and CMS.

•  Translate Medicaid policy into Agile requirements, supporting iterative delivery and sprint-level planning for T-MSIS product teams.

•  Strengthen business development and client relationships by communicating confidently with CMS and state MMIS leadership on program objectives and outcomes.

•  Reduce risk through compliance and certification guidance informed by experience leading multiple MES modules through CMS review processes.

Responsibilities:

•  Provide expert support, analysis, and research into especially complex problems and processes under broad direction.

•  Provide technical direction, interpret requirements, and perform analysis of alternatives.

•  Think independently and demonstrate superior written and oral communications skills.

•  Possess a complete understanding and wide experience in the application of relevant principles, theories, and concepts.

•  Independently develop solutions to complex technical and policy challenges.

•  Apply specialized expertise in Medicaid data systems and a particular domain or area of Information Technology related to T-MSIS.

Candidates must demonstrate deep, hands-on knowledge across multiple Medicaid Enterprise System (MES) domains. Key areas of expertise include:

•  Provider Enrollment and Credentialing — Understanding of provider data submission requirements and how provider enrollment data surfaces in T-MSIS feeds.

•  Member Eligibility — Knowledge of eligibility determination processes and how eligibility data flows into T-MSIS reporting.

•  Claims Adjudication and Encounter Data — Expertise in FFS claims and managed care encounter data processing and validation, including prior authorization (PA) linkage.

•  Pharmacy Benefit Management (PBM) — Familiarity with pharmacy claims data, drug rebate processes, and PBM system configurations.

•  Third Party Liability (TPL) — Understanding of TPL data elements and how they affect T-MSIS data quality and reporting.

•  Enterprise Data Warehouse (EDW) — Experience with Medicaid EDW/decision support systems and their relationship to T-MSIS analytical outputs.

•  Care Management and Program Integrity — Knowledge of care management data flows and program integrity use cases within the T-MSIS data ecosystem.

Ability to apply firsthand knowledge of how state Medicaid systems operate, how state-level policy decisions manifest in data submissions, and how to work effectively within the constraints and realities of state IT environments. Candidates should be able to demonstrate:

State MMIS/MES Architecture & Operations

•  Hands-on experience with state Medicaid Management Information Systems (MMIS) or Medicaid Enterprise Systems (MES), including an understanding of how state system configurations, business rules, and processing logic directly impact the data submitted to T-MSIS.

•  Familiarity with common state MMIS vendor platforms (e.g., DXC, CNSI/Gainwell, Deloitte, Molina, Conduent) and how their system architectures and extract routines affect T-MSIS data quality and completeness.

•  Understanding of state data submission workflows — including how states extract, transform, and transmit T-MSIS files — and the systemic issues that can arise at each stage.

State Medicaid Policy & Program Knowledge

•  Working knowledge of how state-specific Medicaid policy decisions — including managed care contract requirements, benefit plan design, coverage expansions, and waiver programs (e.g., 1115, 1915(b/c)) — affect the structure, completeness, and accuracy of T-MSIS data submissions.

•  Ability to identify when a data quality issue is driven by a policy interpretation or configuration choice at the state level versus a system defect or extraction error, and to advise states on remediation paths for both.

•  Familiarity with state Medicaid managed care arrangements (capitated MCOs, PAHPs, PIHPs, PCCMs) and the encounter data reporting obligations they create, including common data quality challenges in managed care encounter submissions.

•  Understanding of state variation in eligibility determination systems (e.g., integrated MAGI/non-MAGI systems, legacy eligibility platforms) and how eligibility data gaps affect T-MSIS reporting accuracy.

State Engagement & Relationship Management

•  Demonstrated ability to work directly with state Medicaid IT staff, policy analysts, and agency leadership to diagnose data quality issues, explain federal requirements, and build consensus around remediation strategies.

•  Experience navigating state procurement and governance processes, including supporting state RFP development, vendor oversight, and CMS certification submissions.

•  Ability to communicate complex federal data requirements in terms accessible to state staff with varying levels of technical and policy background, adapting communication style to the audience.

•  Track record of building trusted relationships with state Medicaid agencies that enable candid, productive problem-solving on T-MSIS data quality and submission issues.

Required Qualifications: 

• Ability to obtain and maintain a U.S. Federal Government Public Trust clearance.
• U.S. citizenship or ability to meet federal Public Trust eligibility requirements, including applicable residency and work authorization requirements.
• Bachelor’s degree in Computer Science, Information Systems, Engineering, Business, or a related technical or scientific discipline.

In lieu of a degree:

• Minimum of 10 years of professional experience in information technology, including at least 4 years of specialized experience supporting Medicaid systems, health IT programs, or federal health data initiatives.
• Minimum of 5 years of professional experience in Medicaid policy, health IT, MMIS/MES systems, or health data management programs.
• Experience working with T-MSIS, Medicaid data systems, or CMS data programs.
• Experience working with state Medicaid agencies or federal health programs.

Desired Qualifications: 

• 4 or more years of experience supporting MMIS/MES modernization initiatives, Medicaid enterprise strategic planning, or Medicaid systems operations.
• Experience supporting multiple state Medicaid programs across various MES modules or procurement phases.
• Experience working with state MMIS vendor platforms and T-MSIS data submission architectures.
• Experience supporting managed care encounter data validation and reporting, including MCO, PAHP, PIHP, or PCCM models.
• Experience developing a Decision Support System (DSS) or Medicaid data warehouse requirements.
• Experience with cloud-based data architectures and large-scale health data ingestion pipelines.
• Proficiency in data analytics tools or query languages such as SQL, Python, or SAS.
• Experience translating Medicaid policy into Agile user stories and sprint-ready requirements.
• Strong written and verbal communication skills.
• Experience developing training materials or facilitating technical workshops.

Working Environment:
eSimplicity supports a remote work environment operating within the Eastern time zone so we can work with and respond to our government clients. Expected hours are 9:00 AM to 5:00 PM Eastern unless otherwise directed by manager.

Occasional travel for training and project meetings. It is estimated to be less than 5% per year.

Benefits:
We offer a highly competitive salary and full healthcare benefits.

Equal Employment Opportunity:
eSimplicity is an equal-opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, age, status as a protected veteran, sexual orientation, gender identity, or status as a qualified individual with a disability.