Federal Healthcare Programs Subject Matter Expert

The Federal Healthcare Programs Subject Matter Expert (FHPSME) acts as a government healthcare business adviser to both the customer and the project team in all phases of the project. The FHPSME will work collaboratively with the product manager, product owners, business owners, program management team and the data and reporting services teams to deliver business value in support of the Centers for Medicare & Medicaid Services (CMS) in detecting and preventing fraud, waste, and abuse within government-sponsored health programs. The SME will identify emerging trends, recommend modernization opportunities, and help evolve APS capabilities to deliver measurable value, improve fraud detection, and support CMS's long-term program integrity objectives.

ROLE & RESPONSIBILITIES: 

• Provide thought leadership on the future direction of CMS Program Integrity programs and APS capabilities.
• Monitor emerging industry trends, technologies, regulations, and best practices related to healthcare fraud detection and prevention.
• Advise CMS leadership on strategic investments, modernization opportunities, and program enhancements.
• Identify opportunities to expand APS capabilities and increase value delivered to CMS stakeholders.
• Serve as a liaison and trusted partner to CMS business and system owners and key stakeholders including other CMS systems groups and data vendors.
• Apply extensive federal healthcare program knowledge to provide analysis, solutions, and requirements for teams across all areas of the APS project
• Facilitate and participate in client-facing meetings with multiple levels of CMS leadership and end user groups, including requirement gathering sessions, project meetings, and training initiatives.
• Serve as a strategic advisor for the CMS Advanced Provider Screening (APS) program, providing expertise on system dependencies, relationships, and data flows across CMS systems.
• Provide subject matter expertise in Federal Fraud, Waste, and Abuse (FWA) prevention, detection, investigation, and enforcement.
• Interpret and apply HHS regulations, CMS policies, and the Medicare Program Integrity Manual (PIM) to support program integrity initiatives and business operations.
• Advise business and technical teams on compliance with federal healthcare regulations and CMS program integrity standards.
• Provide expertise in Medicare and Medicaid provider licensure verification and criminal background screening to support fraud, waste, and abuse (FWA) prevention and detection.
• Analyse and support CMS programs by applying functional expertise in business processes, system integrations, and data flows across APS, PECOS, UCM, FPS, and related CMS systems.
• Analyse federal and industry data sources, including SSA, Treasury, State Medical Boards, Department of Justice, HRSA, Board Certification, and State Medical Boards, to support provider screening, sanctions, and fraud, waste, and abuse (FWA) detection activities.
• Support the development of business rules, analytical models, and requirements to strengthen FWA prevention and detection efforts.
• Provide guidance on provider enrolment screening, sanctions, ownership disclosures, and risk-based program integrity activities.

REQUIRED EXPERIENCE: 

• Experience in the evaluation, administration, and oversight of federal healthcare programs, with a focus on Medicare and Medicaid.
• Comprehensive knowledge of HHS regulations, the Medicare Program Integrity Manual (PIM), and Medicare and Medicaid program operations.
• Strong understanding of Medicare and Medicaid business processes, policies, and program integrity requirements.
• Excellent verbal and written communication skills, with the ability to effectively engage stakeholders at all levels.
• Strong analytical and problem-solving skills, with the ability to assess complex business and operational challenges.
• Ability to effectively transfer knowledge and mentor team members.
• Proven ability to work in a fast-paced, deadline-driven environment while managing competing priorities.
• Commitment to customer satisfaction through responsiveness, proactive communication, and stakeholder engagement.
• Ability to manage multiple projects, tasks, and client priorities simultaneously. 
• Candidates must be able to obtain and maintain a Public Trust clearance. 
• Candidates must have lived in the United States 3 out of the past 5 years

PREFERRED EXPERIENCE: 

• Knowledge of Agile methodologies, including Scrum, and/or the Scaled Agile Framework (SAFe).
• SAFe Agile certification preferred.
• Understanding of the CMS Targeted Lifecycle (TLC) framework and its application to system development and project delivery.

EDUCATION & CERTIFICATIONS:

• Associates degree or higher