Requirements & Design
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.
Build / Configuration
Supports configuration and implementation activities across Design, Development, and Implementation (DDI). Partners 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). Assists 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. Assists with cutover planning, transition to operations, and hypercare support.
Collaboration & Client Engagement
Partners 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.
