Medicaid SME

  • Full Time
  • Remote
  • This position has been filled

Website CES, LLC

Integrity At Work

Job Description Summary: 

Develop Medicaid and Medicare-Medicaid (Medi-Medi) proactive data analysis for identification of fraud schemes and trends. Provide subject matter expertise and technical assistance on matters related to Medicaid policies and regulations.  Support the Data Analysis, Medical Review, Program Integrity and Request for Information teams by consulting with staff and participating in investigative and/or data analysis efforts.  The SME will perform fraud, waste and abuse detection, deterrence and prevention activities involving Medicare and Medicaid providers, suppliers, and other entities receiving reimbursement under one or both of the Medicare and Medicaid programs.   



Provide subject matter expertise and technical assistance on matters related to Medicaid policies and regulations with the ability to drive ideas for Medicaid proactive studies 
Identification of proactive data studies in the Medicaid program, resulting in identification of high ROI fraud schemes in the Medicaid program, particularly in the states of IL, IN, IA, KS, KY, MI, MN, MO, NE, OH and WI  
Prepare investigative plans 
Remain informed of current Medicaid fraud and abuse issues/schemes through researching reports such as CMS MIG Reviews, OIG State Reports, National Association of Medicaid Directors (NAMD) Briefs and other resources included in the Medicaid SME Research list 
Identify and document state program vulnerabilities 
Attend Medi-Medi meetings with external customers 
Ensure confidentiality of all PHI and sensitive information 
Travel as required for meetings or training 
Perform other duties as assigned 

Minimum required qualifications/skills: 

BA or BS degree and a minimum of three (3) years of Medicaid experience is required, with preference given to those with experience in the states of IL, IN, IA, KS, KY, MI, MN, MO, NE, OH, and WI 
Experience in program integrity or medical review programs 
Excellent oral, written and verbal skills with experience compiling data and writing reports  
Ability to work independently with minimal supervision  
High proficiency level with Microsoft Excel and Word; working knowledge of PowerPoint 
Excellent research skills including internet research 
Must have and maintain a valid driver’s license issued by state of residence 

Preferred qualifications/skills: 

Certified Fraud Examiners (CFE) designation and/or Accredited Healthcare Fraud Investigator (AHFI) designation 

Supervisory Responsibilities: 



Work from Home 

Office Equipment (if a WFH position): 

A locking cabinet and/or desk appropriate for storing documents and electronic media  
A cross-cut or micro-cut (preferred) shredder 
A broadband internet connection with minimum download speed of 15MB – 20MB. (Wireless Air Cards are not approved for work from home use. Free/public wi-fi connections not approved.) 
Telework office connection can be hard-wired direct or Wi-Fi connection. Minimum of WPA2 (Wi-Fi Protected Access II); prefer WPA2 + AES. (WPA and WPE are not approved.) Recommended home wireless standards: Wireless G – Goes through walls, but Medium speed. (Use if router not visible); Wireless N – Great for Speed, but not effective through walls. (Use if router visible); Wireless AC – High speed, but not effective through walls or distance. (Use if router visible) 
Separate phone line (can be a cell phone) 
Office equipment (such as laptop and printer will be provided) 

Physical Requirements: 

May require prolonged periods of sitting at a desk. 


Successful candidates will be required to consent to background checks, credit check and other contract related screenings 
Travel may be required, and all travel expenses, if applicable, are reimbursable via GSA standards