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Medicare Sme Jobs (NOW HIRING)

Nutex Health

Function as a subject matter expert (SME) for Medicare * Function as a subject matter expert (SME) for the following appeals: * Clinical * Medical Necessity * Authorization * Non-Covered

3B Staffing LLC

Business Analyst

Greenwood Village, CO · On-site

Strong preference for Medicare Advantage and deep claims adjudication knowledge. Must have ... They need to be true claim's SME's (ownership- worked in claims operations, not supporting systems ...

3B Staffing LLC

Business Analyst

Greenwood Village, CO · On-site

Strong preference for Medicare Advantage and deep claims adjudication knowledge. Must have ... They need to be true claim's SME's (ownership- worked in claims operations, not supporting systems ...

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Medicare Sme information

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How much do medicare sme jobs pay per hour?

As of Sep 9, 2026, the average hourly pay for medicare sme in the United States is $22.42, according to ZipRecruiter salary data. Most workers in this role earn between $16.11 and $27.16 per hour, depending on experience, location, and employer.

What is a Medicare SME?

A Medicare SME, or Subject Matter Expert, is a professional with specialized knowledge and extensive experience in Medicare policies, regulations, and procedures. They provide guidance on compliance, help interpret complex Medicare rules, and support organizations in navigating the Medicare system. Medicare SMEs often work in healthcare organizations, insurance companies, or consulting firms to ensure adherence to federal guidelines and optimize Medicare-related operations.

What are the key skills and qualifications needed to thrive as a Medicare SME, and why are they important?

To thrive as a Medicare SME, you need in-depth knowledge of Medicare regulations, policies, and billing procedures, often supported by relevant healthcare certifications or experience in Medicare compliance. Familiarity with Medicare claims processing systems, CMS guidelines, and data analysis tools like Excel or healthcare software is crucial. Strong analytical thinking, attention to detail, and effective communication skills help you interpret complex regulatory information and advise stakeholders. These competencies ensure accurate guidance, regulatory compliance, and optimized Medicare operations in healthcare organizations.

What are some common challenges Medicare SMEs face when interpreting complex regulations and how can they stay updated with frequent changes?

Medicare Subject Matter Experts (SMEs) often encounter challenges in keeping up with frequently changing federal regulations and ensuring accurate interpretation for their teams. These complexities require strong attention to detail and proactive engagement with official updates from the Centers for Medicare & Medicaid Services (CMS). To stay current, SMEs typically participate in ongoing training, subscribe to regulatory newsletters, and collaborate with compliance and legal teams. Regularly attending webinars and industry conferences also helps SMEs maintain up-to-date knowledge and provide informed guidance within their organizations.

What is the difference between Medicare Sme vs Medicare Claims Specialist?

AspectMedicare SmeMedicare Claims Specialist
Required CredentialsKnowledge of Medicare policies, certifications like CMS certificationsSimilar certifications, often CMS certifications required
Work EnvironmentHealthcare organizations, insurance companies, consulting firmsHealthcare providers, insurance companies, billing departments
Employer & Industry UsageUsed in healthcare consulting, insurance, and compliance rolesCommon in medical billing, claims processing, and healthcare administration
Search & Comparison IntentUnderstanding role differences, job requirements, career pathsClarifying job responsibilities, qualifications, and work scope

The Medicare Sme typically provides expert advice on Medicare policies and compliance, often working in consulting or advisory roles. The Medicare Claims Specialist focuses on processing and managing Medicare claims within healthcare or insurance organizations. While both roles require knowledge of Medicare regulations and certifications, the Sme offers strategic guidance, whereas the Claims Specialist handles day-to-day claims processing tasks.

What are popular job titles related to Medicare Sme jobs?

For Medicare Sme jobs, the most frequently searched job titles are:

Infographic showing various Medicare Sme job openings in the United States as of September 2026, with employment types broken down into 1% Internship, 5% As Needed, 74% Full Time, 17% Part Time, and 3% Contract. Highlights an 84% Physical, 2% Hybrid, and 14% Remote job distribution, with an average salary of $46,633 per year, or $22.4 per hour.

Federal Healthcare Programs SME (FWA is Must)

Columbia, MD • On-site

Sparksoft Corporation
IT Services • 51 - 200 employees
Learn more about Sparksoft Corporationexternal

Other

Posted 19 days ago

Job description

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


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