Business Analyst — CMdS Claims, Member & Finance Implementation (MES)

Business Analyst — CMdS Claims, Member & Finance Implementation (MES)

Domain: Medicaid Enterprise Systems (MES) | MMIS modernization | Claims / Member / Finance

Role summaryServe as Business Analyst for CMdS product development and implementation on aMedicaid modernization program. Translate legacy MMIS claims, member, and financebehavior and state Medicaid policy into CMdS functional design, requirements, andacceptance criteria. Partner with development, QA, architecture, and businessstakeholders to deliver MES-aligned solutions that replace or integrate with legacyadjudication, eligibility/enrollment, and financial accounting processes.

Key responsibilitiesDelivery & analysis Own requirements and functional design for assigned CMdS modules (Claims,Member, Finance, and related interfaces). Define epics, user stories, and definition of done; prioritize against Medicaidpolicy, MES certification goals, and release plans. Facilitate working sessions; clarify requirements for developers and QA; resolvefunctional questions during build and test. Track scope, dependencies, risks, and decisions; maintain traceability fromlegacy rule to CMdS design to test evidence.Functional design (Claims, Member, Finance) Claims: Lead functional design for claim intake, claim type assignment,validity/pricing edits, adjustment/void, crossover, encounters, remittance, andrelated edit disposition behavior; map legacy rules to CMdS configuration andcustomizations. Member: Lead design for eligibility spans, aid category / benefit packageassignment, enrollment, MCO/FFS indicators, and interfaces from state eligibilitysystems into CMdS Member.

 Finance: Lead design for payment cycles, budget account / category of service,fund splits, ASO / F/EA and other administrative payment paths, financialtransactions, and reporting/accounting controls. Produce BRDs, FRDs, process flows, data mapping, gap analysis, andconfiguration workbooks suitable for build and UAT.Collaboration with Development & QA Work side-by-side with developers on design walkthroughs, edge cases, anddefect triage. Partner with QA to define test scenarios, expected results, and regression packs(positive/negative, adj/void, crossover, encounter, finance posting). Support SIT, UAT, and parallel/run-compare activities against legacy MMISoutcomes. Validate that implementations meet Medicaid policy and MES operationalreadiness (security, audit, reporting, interfaces).Stakeholder & MES engagement Run workshops with business owners, SMEs, fiscal, and operations. Align designs to CMS MES expectations (modularity, interoperability, standards-based interfaces, certification evidence). Support change management: training outlines, release notes, and operationalrunbooks for CMdS go-live.

Required qualifications 12+ years business analysis experience in Medicaid MMIS / MES, with deephands-on work in at least two of: Claims, Member/Eligibility-Enrollment,Finance/Financial Accounting. Experience modernizing or replacing legacy MMIS (COBOL/mainframe orequivalent) with a commercial Medicaid platform. Strong Medicaid domain knowledge, including:o FFS vs managed care; capitation vs ASO / administrative services models

o Claim types, media sources, edits/EOBs, adjustments/voids, Medicarecrossover, encounterso Aid categories, benefit packages, eligibility spans, timely filing, TPLconceptso Provider payments, remittance advice, budget/object codes, COS, fundsource / FFP conceptso CMS / state Medicaid policy drivers relevant to MES implementation andcertification

 Demonstrated ability to write clear functional design and acceptance criteria forcomplex adjudication and financial rules. Experience working embedded with development and QA teams in Agile orhybrid SDLC. Excellent facilitation, documentation, and stakeholder communication skills.

Preferred qualifications Hands-on CMdS configuration or implementation (Claims, Member, Finance,Reference, Service Auth). Familiarity with HIPAA X12 (837/835), COBA/crossover, EVV-related claim flows. Experience supporting CMS MES certification artifacts and evidence packages. Prior lead BA experience on multi-module MES releases.

Soft skills Comfortable owning ambiguity when legacy rules are incomplete; drivesdecisions with SMEs. Balances policy accuracy with delivery timelines. Credible with technical teams and business executives alike.

Originally posted on Himalayas