专业领域专家 - 医疗保险行政承包商（MACs）
Subject Matter Expert - Medicare Administrative Contractors (MACs)
职责
Peraton 正在寻找一位在医疗保险行政承包商（MACs）方面具有丰富经验的专家，以支持跨医疗保险按服务付费（FFS）生态系统的关键 CMS 运营。作为国家领先的任务能力集成商，以及被信任来交付复杂联邦健康项目的行业合作伙伴，Peraton 依赖专家提供深入的运营专业知识、战略指导和数据驱动的见解。此职位确保 Peraton 的 CMS 项目团队、项目经理和技术负责人具备有关 MAC 功能、法规和交互的权威知识，这些是医疗保险 FFS 运营环境的基础。
主要职责：
- 作为医疗保险行政承包商（MACs）的首席专家，包括 A/B MACs 和 DME MACs，了解其目的、结构和范围，以及它们作为 CMS 与提供者之间主要操作接口的关键作用。
- 为项目团队提供建议，涉及 MAC 的运营职责，如理赔处理、付款会计、提供者注册、申诉（重新确定）、医疗审查、提供者教育以及地方覆盖决定的制定。
- 提供关于 MAC 规模、理赔数量、提供者人口和医疗保险 FFS 福利支付的见解，以支持 Peraton 的项目分析和绩效评估。
- 指导团队理解 MAC 在医疗保险 FFS 生态系统中与关键功能承包商的关系，包括 RACs、UPICs、VDCs、QIOs、QICs、SMRCs、BCRC、CCO 和 HIGLAS。
- 通过解释 CMS 采购要求、法规、历史指导以及《医疗保险处方药改进与现代化法案》下 MAC 的演变，支持项目的联邦合同和合规活动。
- 与区域项目经理、分析师和技术负责人合作，评估 MAC 运营，识别运营改进领域，并确保与 CMS 项目目标和承包商义务保持一致。
- 为解决方案开发、提案撰写、需求分析、风险识别、运营手册、技术文档和面向客户的交付物贡献专业知识。
- 通过确保团队理解 MAC 如何作为医疗保险 FFS 活动的核心，以及这如何影响互操作性、数据流和项目表现，推进 Peraton 的使命。
资格要求
所需经验和资质
- 至少 12 年工作经验，拥有学士学位；或 16 年工作经验
查看英文原文
Responsibilities
Peraton is seeking a highly experienced Subject Matter Expert (SME) specializing in Medicare Administrative Contractors (MACs) to support mission‑critical CMS operations across the Medicare Fee‑For‑Service (FFS) ecosystem. As the nation’s leading mission capability integrator and the industry partner trusted to deliver complex federal health programs, Peraton relies on SMEs to provide deep operational expertise, strategic guidance, and data‑driven insights. This role ensures that Peraton’s CMS program teams, project managers, and technical leads have authoritative knowledge on MAC functions, regulations, and interactions that underpin the Medicare FFS operational environment.
Key Responsibilities:
- Serve as lead expert on the purpose, structure, and scope of Medicare Administrative Contractors (MACs), including A/B MACs and DME MACs, and their critical role as CMS’s primary operational interface with providers.
- Advise project teams on MAC operational responsibilities such as claims processing, payment accounting, provider enrollment, appeals (redeterminations), medical review, provider education, and the development of Local Coverage Determinations.
- Provide insight on MAC scale, claim volumes, provider populations, and Medicare FFS benefit disbursements to support Peraton’s program analysis and performance evaluations.
- Guide teams in understanding MAC relationships with key functional contractors in the Medicare FFS ecosystem, including RACs, UPICs, VDCs, QIOs, QICs, SMRCs, BCRC, CCO, and HIGLAS.
- Support project’s federal contracting and compliance activities by interpreting CMS procurement requirements, regulations, historical guidance, and the evolution of MACs under the Medicare Prescription Drug Improvement and Modernization Act.
- Partner with area project managers, analysts, and technical leads to evaluate MAC operations, identify areas for operational enhancement, and ensure alignment with CMS program goals and contractor obligations.
- Contribute subject matter expertise to solution development, proposal writing, requirements analysis, risk identification, operational playbooks, technical documentation, and customer‑facing deliverables.
- Advance Peraton’s mission by ensuring teams understand how MACs operate as the hub of Medicare FFS activities and how this affects interoperability, data flows, and program performance.
Qualifications
Required Experience and Qualifications
- Minimum of 12 years with BS/BA; or 16 years of experience with a high school diploma.
- Extensive knowledge of Medicare Fee‑For‑Service program operations and CMS contractor structures.
- Experience with all claim types: Part A, Part B, Home Health & Hospice, Railroad Board, DME
- Expertise in claims adjudication, provider enrollment workflows, appeals processes, medical review, and coverage determination development.
- Experience with Medicare Claims Pricing, CMS Web Pricer, Prospective Payment Systems and Fee Schedules
- Demonstrated experience working with or supporting CMS, Medicare contractors, or large federal health programs.
- Understanding of MAC relationships with key functional contractors across the FFS landscape (RACs, UPICs, QIOs, QICs, VDCs, SMRCs, etc.).
- Understanding of edits used by MACs and working suspense codes
- Understanding of reporting needs/uses from claims systems
- Understanding of Provider and/or Bene workflows for claims processing and payments
- Strong familiarity with CMS regulations, guidance, and acquisition requirements.
- Proven ability to communicate complex program information to diverse stakeholders including federal customers, program managers, and multi‑disciplinary teams.
- Ability to obtain a Public Trust clearance.
- US Citizen or Green Card Holder.
Preferred Qualifications
- Experience with specific claims workflow processes for NGS/WellPoint Federal and workload balancing/assignments
- Experience with specific systems built by NGS/WellPoint Federal to help automate claims processing
- Direct experience with MAC operations, oversight, or support.
- Background in Medicare policy, health care administration, program integrity, or government contracting.
Peraton Overview
Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers. Visit peraton.com to learn how we’re keeping people around the world safe and secure.
Target Salary Range
$146,000 - $234,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.EEO
EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.Originally posted on Himalayas