Medicare Subject Matter Expert
Pay Range: $35 - $40 per hour based on experience Work Hours: Approximately 40 hours per month Location: Remote Summary: The Medicare Subject Matter Expert (SME) provides in-depth expertise on Medicare rules, regulations, and operational requirements related to claims adjudication, payment accuracy, and audit readiness. This role supports internal teams by interpreting CMS guidance, ensuring compliance with Medicare Parts A/B/C/D policies. The Subject Matter Expert (SME) serves as a key resource and advisor on project initiatives. This individual provides strategic insight, expert guidance, and advanced support to ensure the successful execution of project requirements. The SME represents the organization as a recognized authority in their field and applies their knowledge to meet business and technical objectives. The SME is a key resource for translating regulatory requirements into operational workflows and helping the organization respond effectively to CMS, internal, and external audit activities. Responsibilities and Duties: The following reflects managements definition of essential functions for this job but does not restrict the tasks that may be assigned. Management reserves the right to assign or reassign responsibilities, as necessary.
Understands, articulates, and implements best practices related to Medicare program.
Serves as the internal expert on CMS regulations related to claims payment, coverage criteria, billing rules, benefit design, and appeals.
Leads or participates as an active participant of project work-groups.
Analyzes claims trends, payment errors, and audit findings to identify root causes and operational fixes.
Provides guidance on how to resolve issues related to project.
Authors project-related plans, reports, requirements, training materials, policy documentation and other documentation as assigned.
Reviews and critiques draft plans, reports and other documentation authored by other project resources as assigned.
Coordinates with mentors and provides training and assistance to other project personnel.
Cultivates and maintains effective working relationships with stakeholders, including end-users, project managers, and management staff.
Translates subject matter terminology into business terms.
Qualifications:
Bachelors degree in Healthcare Administration, Public Health, Nursing, Business, Policy, or a related field.
Ten (10) or more years of proven experience with Medicare programs
In-depth understanding of Medicare Parts A, B, C (Medicare Advantage), and/or D.
Experience with Medicare rules, operational workflows, payment methodologies, and compliance standards.
Experience reviewing CMS guidance and translating it into business requirements.
Strong knowledge of: CMS Program Audit protocols, Medicare Managed Care Manual, Claims Processing Manual, Medicare Benefit Policy Manual, and/or Payment methodologies and coverage guidelines
Skilled at explaining complex Medicare rules to internal teams.
Articulates and communicates information effectively to diverse audiences
Commitment to excellence and high standards
Excellent written and oral communication skills
Strong organizational, problem-solving and analytical skills
Ability to manage priorities and workflow
Versatility, flexibility, and willingness to work within constant changing priorities
Proven ability to manage multiple projects and meet deadlines
Demonstrated good judgment with the ability to make timely and sound decisions
Experience with MS Teams, SharePoint, MS Suite,
Experience using and applying Artificial Intelligence (AI) in the workplace
NHA is a state and federal government contractor; all employees must be legally authorized to work in the United States. NHA does not provide sponsorship at this time.
NHA is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, sexual orientation, national origin, veteran status, disability or any other basis protected by law.
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Medicare Subject Matter Expert
Pay Range: $35 - $40 per hour based on experience Work Hours: Approximately 40 hours per month Location: Remote Summary: The Medicare Subject Matter Expert (SME) provides in-depth expertise on Medicare rules, regulations, and operational requirements related to claims adjudication, payment accuracy, and audit readiness. This role supports internal teams by interpreting CMS guidance, ensuring compliance with Medicare Parts A/B/C/D policies. The Subject Matter Expert (SME) serves as a key resource and advisor on project initiatives. This individual provides strategic insight, expert guidance, and advanced support to ensure the successful execution of project requirements. The SME represents the organization as a recognized authority in their field and applies their knowledge to meet business and technical objectives. The SME is a key resource for translating regulatory requirements into operational workflows and helping the organization respond effectively to CMS, internal, and external audit activities. Responsibilities and Duties: The following reflects managements definition of essential functions for this job but does not restrict the tasks that may be assigned. Management reserves the right to assign or reassign responsibilities, as necessary.
Understands, articulates, and implements best practices related to Medicare program.
Serves as the internal expert on CMS regulations related to claims payment, coverage criteria, billing rules, benefit design, and appeals.
Leads or participates as an active participant of project work-groups.
Analyzes claims trends, payment errors, and audit findings to identify root causes and operational fixes.
Provides guidance on how to resolve issues related to project.
Authors project-related plans, reports, requirements, training materials, policy documentation and other documentation as assigned.
Reviews and critiques draft plans, reports and other documentation authored by other project resources as assigned.
Coordinates with mentors and provides training and assistance to other project personnel.
Cultivates and maintains effective working relationships with stakeholders, including end-users, project managers, and management staff.
Translates subject matter terminology into business terms.
Qualifications:
Bachelors degree in Healthcare Administration, Public Health, Nursing, Business, Policy, or a related field.
Ten (10) or more years of proven experience with Medicare programs
In-depth understanding of Medicare Parts A, B, C (Medicare Advantage), and/or D.
Experience with Medicare rules, operational workflows, payment methodologies, and compliance standards.
Experience reviewing CMS guidance and translating it into business requirements.
Strong knowledge of: CMS Program Audit protocols, Medicare Managed Care Manual, Claims Processing Manual, Medicare Benefit Policy Manual, and/or Payment methodologies and coverage guidelines
Skilled at explaining complex Medicare rules to internal teams.
Articulates and communicates information effectively to diverse audiences
Commitment to excellence and high standards
Excellent written and oral communication skills
Strong organizational, problem-solving and analytical skills
Ability to manage priorities and workflow
Versatility, flexibility, and willingness to work within constant changing priorities
Proven ability to manage multiple projects and meet deadlines
Demonstrated good judgment with the ability to make timely and sound decisions
Experience with MS Teams, SharePoint, MS Suite,
Experience using and applying Artificial Intelligence (AI) in the workplace
NHA is a state and federal government contractor; all employees must be legally authorized to work in the United States. NHA does not provide sponsorship at this time.
NHA is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, sexual orientation, national origin, veteran status, disability or any other basis protected by law.