Description

Key responsibilities

• Own requirements and functional design for assigned CMdS modules (Claims, Member, Finance, and related interfaces).
• Define epics, user stories, and definition of done; prioritize against Medicaid policy, MES certification goals, and release plans.
• Facilitate working sessions; clarify requirements for developers and QA; resolve functional questions during build and test.
• Track scope, dependencies, risks, and decisions; maintain traceability from legacy rule to CMdS design to test evidence.
• Functional design (Claims, Member, Finance)
• Claims: Lead functional design for claim intake, claim type assignment, validity/pricing edits, adjustment/void, crossover, encounters, remittance, and related edit disposition behavior; map legacy rules to CMdS configuration and customizations.
• Member: Lead design for eligibility spans, aid category / benefit package assignment, enrollment, MCO/FFS indicators, and interfaces from state eligibility systems into CMdS Member.
• Finance: Lead design for payment cycles, budget account / category of service, fund splits, ASO / F/EA and other administrative payment paths, financial transactions, and reporting/accounting controls.
• Produce BRDs, FRDs, process flows, data mapping, gap analysis, and configuration workbooks suitable for build and UAT.
• Collaboration with Development & QA
• Work side-by-side with developers on design walkthroughs, edge cases, and defect triage.
• Partner with QA to define test scenarios, expected results, and regression packs (positive/negative, adj/void, crossover, encounter, finance posting).
• Support SIT, UAT, and parallel/run-compare activities against legacy MMIS outcomes.
• Validate that implementations meet Medicaid policy and MES operational readiness (security, audit, reporting, interfaces).
• Stakeholder & MES engagement
• Run workshops with business owners, SMEs, fiscal, and operations.
• Align designs to CMS MES expectations (modularity, interoperability, standards-based interfaces, certification evidence).
• Support change management: training outlines, release notes, and operational runbooks for CMdS go-live.

Required qualifications

• 12+ years business analysis experience in Medicaid MMIS / MES, with deep hands-on work in at least two of: Claims, Member/Eligibility-Enrollment, Finance/Financial Accounting.
• Proven experience developing and implementing claims systems / MMIS / MES platforms, such as Conduent CMdS (Conduent Medicaid Suite), Health Enterprise, QNXT, Facets, or comparable commercial Medicaid/claims suites.
• Experience modernizing or replacing legacy MMIS (COBOL/mainframe or equivalent) with a commercial Medicaid platform.
• Strong Medicaid domain knowledge, including:
• FFS vs managed care; capitation vs ASO / administrative services models
• Claim types, media sources, edits/EOBs, adjustments/voids, Medicare crossover, encounters
• Aid categories, benefit packages, eligibility spans, timely filing, TPL concepts
• Provider payments, remittance advice, budget/object codes, COS, fund source / FFP concepts
• CMS / state Medicaid policy drivers relevant to MES implementation and certification
• Demonstrated ability to write clear functional design and acceptance criteria for complex adjudication and financial rules.
• Experience working embedded with development and QA teams in Agile or hybrid SDLC.
• Excellent facilitation, documentation, and stakeholder communication skills

Key Skills

Education

Bachelor's degree