Federal Healthcare Programs Subject Matter Expert
Core
Acts as a government healthcare business adviser to the Centers for Medicare & Medicaid Services (CMS) to detect and prevent fraud, waste, and abuse within government-sponsored health programs.
Role type
Senior Subject Matter Expert (Program Integrity)
Builds
Strategic advice, business rules, and analytical models for CMS program integrity
Domain
US Federal Healthcare (Medicare/Medicaid) and Fraud Detection
Deliverable
production ML models
Required skills
Federal healthcare program administration, HHS regulations, Medicare Program Integrity Manual, Medicare/Medicaid business processes, Fraud detection, Provider licensure verification, Criminal background screening, Data flow analysis, Business rule development
Preferred skills
Agile/Scrum/SAFe, CMS Targeted Lifecycle framework
Technologies
CMS systems (APS, PECOS, UCM, FPS), SSA, Treasury, State Medical Boards, DOJ, HRSA
Responsibilities
Provide thought leadership on CMS Program Integrity programs, Monitor emerging industry trends and regulations, Advise CMS leadership on strategic investments, Identify opportunities to expand APS capabilities, Serve as a liaison to CMS stakeholders, Apply federal healthcare knowledge to provide analysis and solutions, Facilitate client-facing meetings with CMS leadership, Interpret HHS regulations and CMS policies, Advise teams on compliance with federal healthcare regulations, Provide expertise in FWA prevention and detection, Analyse federal and industry data sources, Support development of business rules and analytical models, Provide guidance on provider enrolment screening and risk-based activities
Seniority
Senior, hands-on IC
