Advisor Business Analyst - MMIS / Medicaid Pharmacy

Gainwell Technologies is a company focused on improving healthcare operations through innovative solutions. The Advisor Business Analyst - MMIS / Medicaid Pharmacy role involves supporting business, policy, and technical execution within Medicaid Management Information Systems (MMIS) and the Medicaid Pharmacy environment, ensuring compliance and successful implementation of Medicaid policies and program requirements.

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 or similar healthcare claims/encounter 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