Senior Medicaid Business Analyst (Configuration & Policy)

Gainwell Technologies delivers Medicaid management information systems and healthcare technology solutions. The Senior Medicaid Business Analyst supports end-to-end Medicaid domain delivery by translating state and federal policy into requirements, product features, system configuration, and design artifacts, while providing subject-matter expertise across implementation, testing, deployment, and client engagement.

Responsibilities:

• Acts as the primary Domain SME, serving as a trusted advisor to the Engagement Lead (EL) on business processes and associated regulatory and operational impacts
• Ensures compliance alignment by validating that solution design and configuration conform to CMS guidance, state policy, and documented business rules
• Supports the EL with in-scope negotiations and change control, providing domain expertise to assess scope trade-offs and the functional, regulatory, and operational impacts of change requests
• Lead and participate in collaborative requirements and design sessions with clients and internal teams to validate functional and technical needs
• Interpret state and federal Medicaid policy, regulations, and program rules and translate them into product features, system configuration, business rules, and design artifacts
• Serve as a policy and domain SME, supporting the Domain Lead with analysis, interpretation, and solution recommendations
• Develop and maintain domain design documentation, with the Design Document as a core deliverable, covering workflows, interfaces, X12 EDI transactions, letters, and reports
• Ensure accuracy, completeness, and traceability of requirements and acceptance criteria
• Document and communicate domain-level decisions, risks, assumptions, and dependencies, assessing downstream impacts
• Support domain-specific configuration and implementation activities within Design, Development, and Implementation (DDI) projects
• Responsible for configuration and partner with technical teams to ensure solutions align with approved design documentation, Medicaid policy interpretation, and documented business rules
• Key configurations include but not limited to:
  • Claims: Edits, pricing, benefit limits,, adjudication logic
  • Plan: Contracts, benefits, programs, fee schedules
  • Provider: Provider types, specialties, contracts, enrollment, credentialing
  • Member: Eligibility, benefits, benefit plans, demographic
  • Pharmacy: RX benefits, RX claims processing
• Review test cases to ensure alignment with requirements, policy interpretation, and acceptance criteria
• Provide domain SME support during System Integration Testing (SIT) and User Acceptance Testing (UAT)
• Support defect analysis, root-cause investigation, resolution, retesting, and functional readiness validation
• Support operational readiness activities, including environment, data, process, and staffing readiness
• Provide domain and policy input for Operational Readiness Reviews (ORR), parallel testing, and performance testing
• Support cutover preparation, transition to operations, and hypercare activities
• Work closely with the Domain Lead and Technical Analysts, acting as a trusted domain and policy SME
• Lead and support client communication, including requirement discussions, design reviews, and issue resolution
• Plan and deliver functional demos and solution walkthroughs to showcase product features and validate alignment with client requirements
• Facilitate and participate in collaborative working sessions with business stakeholders, configuration teams, and technical teams
• Support documentation, knowledge transfer, and ongoing operational support

Requirements:

• Bachelor's degree in Computer Science, Information Systems, Health Informatics, or a related field
• 5 to 8 years of hands‑on experience supporting healthcare system implementations, including MMIS solutions and Medicaid Pharmacy platforms
• Experience with QNXT similar healthcare provider/claims management systems
• Strong knowledge of state and federal Medicaid policy, regulations, and program rules (required)
• Strong understanding of Medicaid domains, including claims, member, provider, and prior authorization processes
• Demonstrated experience translating policy and program rules into system requirements, configuration support, and design artifacts
• Strong knowledge of SQL is required, particularly for data analysis and validation
• Strong client communication skills, with experience interacting directly with business stakeholders
• Proven ability to lead or support functional demonstrations, walkthroughs, and collaborative working sessions
• Strong documentation, facilitation, and analytical skills
• Experience working in SDLC and Agile delivery environments
• Knowledge of MITA (Medicaid Information Technology Architecture)
• Experience with system integrations, EDI/X12 transactions, analytics, and reporting
• Familiarity with state and federal healthcare regulations and compliance standards