Medicaid Claims Operations Consultant

NTT DATA Services•Montgomery, AL

9d•$110,625 - $175,000•Remote

About The Position

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. Works directly with client CPMS and EDS program manager(s) on planning and executing changes to the existing system in preparation for cutover to the CPMS and EDS. The Operations Lead will provide guidance and insight on the operational aspects of migrating the Fiscal Agent responsibilities to the CPMS vendor. These include transition to a new location, if needed, transition and cutover of operational units including call center, provider enrollment, mail room, prior authorization units, pharmacy operations, and EDI operations. The Operations Lead will work with Business Analysts from the Agency and NTT DATA on activities in both the AMMIS system and the CPMS necessary for the effective transition. The Operations Lead will work with the CPMS and EDS project managers and program managers to prepare and execute the Operational Readiness Review with CMS. Additionally, this individual will aid the client in maintaining the relationship with the existing MMIS contractor and work with the CPMS and EDS contractors to ensure a successful transition. General responsibilities include status reporting, meeting facilitation, and other project related services, at the direction of the NTT DATA contract leadership.

Requirements

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.

Nice To Haves

Strong understanding of MMIS claims processing and Medicaid business workflows (claims, payments, provider interactions)
Ability to assess operational impacts of system changes across integrated MES modules
Knowledge of CMS certification expectations (OBC/SMC) and MITA framework
Ability to evaluate transition risks and ensure operational readiness for large-scale system changes
Familiarity with cloud-based architecture and data/integration patterns in Medicaid environments
PMP, ITIL, or equivalent industry certifications

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. focusing on readiness for claims processing, payment cycles, provider enrollments and business continuity.
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.
Coordinate and validate completeness and accuracy of knowledge transfer and 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.