[Hiring] Business Process Analysis SME @Gainwell Technologies LLC

Role Description

Seeking an experienced BPA SME with Medicaid domain expertise and strong understanding of MS MES Business Policy Administration. The candidate will be responsible for analyzing Medicaid policy requirements, translating policies into BPA rules, supporting Benefit Plans, Assignment Plans, Provider Contracts, and ensuring accurate claims adjudication through BPA configuration and governance.

The BPA SME will collaborate with Business Analysts, DOM SMEs, Operations, Reference teams, Developers, and Testing teams to design, configure, validate, and maintain BPA rule solutions. BPA supports claims adjudication, coverage determination, provider billing validation, reimbursement, audits, copays, and other insurance processing.

This role is strictly involved in business process analysis, requirements gathering and does not involve direct access to Protected Health Information (PHI), Personally Identifiable Information (PII), or any secured or confidential client data. The work is limited to business process analysis and does not include handling or processing of sensitive health or personal information.

Qualifications

• Medicaid Claims Processing
• Medicaid Policy Interpretation
• Benefit Plan Analysis
• Assignment Plan Analysis
• Provider Contract Analysis
• BPA Rule Analysis
• Requirements Gathering
• Impact Analysis
• Business Rule Documentation

Requirements

• SQL
• Oracle
• C Programming (working knowledge)
• Pro*C (working knowledge)
• Unix/Linux
• Data Mapping
• Query Analysis

Benefits

• Remote opportunity

Your role in our mission

• Business Policy Analysis
  • Analyze Federal and State Medicaid policy requirements.
  • Translate policy requirements into BPA rule specifications.
  • Create decision tables, rule mapping documents, and business rule specifications.
• BPA Configuration Analysis
  • Analyze and support:
    • Benefit Plans
    • Assignment Plans
    • Provider Contracts
    • Reimbursement Rules
    • Copay Rules
    • Audit Rules
    • Form Edit Rules
• Claims Processing Analysis
  • Understand how BPA impacts claim adjudication.
  • Analyze:
    • Coverage determination
    • Provider eligibility validations
    • Provider contract validations
    • Reimbursement processing
• Rule Sheet Management
  • Review and validate BPA Rule Sheets.
  • Support BPA Rule Sheet release management process.
  • Review approvals and configuration promotions.
  • Perform rule impact analysis.
  • Validate overlapping rule scenarios.
  • Support BPA Rule Sheet governance.
• Testing & Validation
  • Create acceptance criteria.
  • Develop BPA test scenarios.
  • Perform policy compliance verification.

BPA Knowledge

• Business Rules Editor (BRE)
• Rule Sheets
• Benefit Classifications
• Rule Metadata
• Rule Variables
• Benefit Plan Hierarchies
• Provider Contracts
• Rule Configuration Lifecycle

Preferred Skills

• MES/MESA Experience
• Medicaid Enterprise Systems
• Claims Adjudication Knowledge
• Provider Enrollment & Maintenance
• Reference Data Knowledge
• Rule Engine Experience