Senior Medicaid Eligibility & Enrollment business analyst/SME

Medicaid Eligibility & Enrollment Business Analyst/SME

We are seeking a highly experienced Medicaid Eligibility & Enrollment Business Analyst/SME with over 15 years of experience supporting large-scale Medicaid programs, eligibility systems, and healthcare operations. The ideal candidate will possess deep functional knowledge of Medicaid eligibility and enrollment processes, policy interpretation, systems analysis, and operational support. This role will support Medicaid modernization initiatives, eligibility operations, system enhancements, defect analysis, business process improvements, and stakeholder coordination across business and IT teams.

Key Responsibilities

• Analyze Medicaid eligibility and enrollment business processes, workflows, and system functionality.
• Interpret federal and state Medicaid policies and translate requirements into functional specifications.
• Support eligibility determination processes for programs including MAGI, Non-MAGI, CHIP, SNAP integration, and related public assistance programs.
• Work closely with operations teams, system integrators, and development teams to resolve eligibility and enrollment issues.
• Perform root cause analysis for eligibility defects, enrollment discrepancies, and data inconsistencies.
• Develop business requirements documents (BRDs), functional specifications, user stories, and process flows.
• Support UAT, SIT, regression testing, and production validation activities.
• Assist with data analysis, reconciliation, and reporting related to eligibility and enrollment transactions.
• Coordinate with state agencies, vendors, and business stakeholders on system enhancements and operational initiatives.
• Provide production support and guidance during critical implementation and renewal periods.
• Participate in policy workshops, backlog grooming sessions, and operational review meetings.
• Mentor junior analysts and provide subject matter expertise to project teams.

Required Qualifications

• 15+ years of experience in Medicaid eligibility and enrollment systems and operations.
• Strong understanding of Medicaid eligibility rules, enrollment lifecycle, renewals, Stacking, notices, and case management processes.
• Mandatory experience working with large system integrators, healthcare vendors, or state Medicaid programs.
• Experience working on large state Medicaid programs and integrated eligibility systems.
• Experience supporting Medicaid modernization or eligibility transformation initiatives.
• Strong analytical, problem-solving, and communication skills.
• Experience working with business and technical teams in Agile and/or Waterfall environments.
• Ability to analyze large datasets and identify operational or system issues.
• Experience with defect triage, production support, and operational stabilization activities.

Preferred Qualifications

• Experience with platforms such as Pega, Curam, Salesforce, or other eligibility systems.
• Knowledge of CMS, ACA, MAGI, and state Medicaid compliance requirements.
• Familiarity with healthcare interoperability and data exchange processes.
• Experience supporting call center operations, renewals, and eligibility reconciliation efforts.
• SQL or PowerBI experience required.