SME- Clinical Laboratory Fee Schedule (CLFS)

Position- SME- Clinical Laboratory Fee Schedule (CLFS) Location- Woodlawn, MD Type- Remote, with periodic travel to CMS Visa- U.S. Citizen (Ability to obtain CMS Public Trust (Moderate) Key Responsibilities • Serve as the contract''''s authoritative interpreter of PAMA Section 216, 42 CFR Part 414 Subpart G, and CMS sub-regulatory guidance governing CLFS private payor rate reporting, applicable laboratory determination, applicable information, and the weighted median rate-setting methodology. • Translate CMS policy decisions and rulemaking outcomes into validated business requirements, requirements traceability matrices, and acceptance criteria for development teams working under the CMS Expedited Life Cycle (XLC) framework. • Author and maintain data validation rule sets for the CLFS submission process, including TIN-level submission integrity, HCPCS code applicability, private payor rate plausibility, volume edits, and reporting-entity-to-applicable-laboratory mappings. • Support the CLFS data reporting cycle end-to-end: pre-reporting outreach, submission (file upload and manual entry), CFO/President certification via OTP, validation, calculation of weighted medians, publication of rates, and post-publication corrections. • Define and review test cases covering submitter and certifier role workflows, data ingestion, edit checks, calculation outputs, and publication files; participate in code walkthroughs and validation testing. • Provide Tier 3 escalation support for help desk inquiries from reporting entities, applicable laboratories, certifying officials, and CMS staff on complex policy and business-process questions. • Develop and maintain CLFS sections of the User Manual, Operator Manual, training plan, and training materials, ensuring Section 508 conformance. • Support Authority to Operate (ATO) activities, annual Security Controls Assessments, and CFACTS documentation from a business-owner perspective. • Brief CMS leadership on data trends, submission compliance, and impacts of proposed policy changes; provide analytical support to inform Physician Fee Schedule rulemaking and other CMS proposals affecting CLFS. • Coordinate with Medicare Administrative Contractors (MACs), CMS Shared Services (CMS Enterprise Portal, IDM/EIDM), and other stakeholders as CLFS data is consumed by downstream payment systems. Required Qualifications • Bachelor''''s degree in health policy, health administration, public health, life sciences, economics, or a related field. • Minimum 7 years of progressive experience in Medicare Part B payment policy or clinical laboratory reimbursement, including at least 3 years working directly with CLFS, PAMA private payor rate reporting, or clinical lab billing operations. • Working knowledge of HCPCS Level I (CPT) and Level II laboratory codes, the CLFS rate-setting methodology (weighted median of private payor rates), and the distinction between CDLTs and Advanced Diagnostic Laboratory Tests (ADLTs). • Understanding of CLIA certification, the statutory “applicable laboratory” and “applicable information” definitions, the majority-of-Medicare-revenues threshold, and low-expenditure thresholds. • Demonstrated ability to translate statute and regulation into discrete, testable system requirements. • Experience supporting CMS or other federal contracts operating under a formal SDLC (XLC, EPLC, or equivalent). • Familiarity with CMS Enterprise Portal, IDM (formerly EIDM), CFACTS, and CMS Acceptable Risk Safeguards (ARS). • Strong written communication skills; able to produce policy memoranda, user-facing instructions, and engineering-grade requirements with equal clarity. Preferred Qualifications • Master''''s degree (MHA, MPH, MPP, or equivalent). • Prior experience as a contractor or federal employee on a CMS payment system (CLFS, ASP, PFS, OPPS, or AFS). • Direct experience inside a clinical laboratory''''s reimbursement, compliance, or finance function. • Familiarity with the CY Physician Fee Schedule (PFS) rulemaking cycle and how CLFS provisions move through proposed/final rules. • Working knowledge of Section 508 / 36 CFR Part 1194 accessibility requirements. • Experience with statistical or actuarial review of payment rate calculations. • Familiarity with Agile/Scrum delivery within an XLC-governed program. Thanks & Regards Shivam Rajpal Team Lead- US IT Recruitment Desk- X 106 Email- LinkedIn- Voto Consulting LLC- M/WBE Certified Company