OverviewOverview:
HealthEdgeis seeking a Product Manager with deepexpertisein CMS Medicare Fee-for-Service provider data standards to join theHealthRulesPayer product team. In this role, you will own the product requirements that define how health plans onboard,validate,maintainand operationalize provider data within theHealthRulesPayer platform ensuring alignment with CMS enrollment,credentialingand revalidation mandates.
You will partner cross-functionally with engineering, QA,implementationand client success to ensureHealthRulesPayer provider data capabilities areaccurate,compliantand scalable empowering our health plan clients to meet provider directory accuracy obligations and support clean claims adjudication.
What You Will Own:
The product requirements governing provider data standards, NPI validation, taxonomy classification, PECOSalignmentand provider directory accuracy obligations withinHealthRulesPayer ensuring health plan clients meet CMS provider data integrity mandates.
What you'll do:
Provider Data Management
- DevelopHealthRulesPayer product requirements supporting CMS Medicare FFS provider data standards, including NPI validation, taxonomy classification, specialtymappingand provider file maintenance aligned to HIPAA standard transaction requirements.
- EnsureHealthRulesPayer provider configuration capabilities align with CMS enrollment,credentialingand revalidation mandates including requirements for PECOS data alignment and provider directory accuracy obligations.
- Define requirements for provider data ingestion and maintenance workflows withinHealthRulesPayer, including automated validation rules, exceptionhandlingand provider data reconciliation processes.
- Translate CMS provider data regulatory updates including PECOS revalidation cycles, taxonomy code set changes and NPI Registry alignment requirements into structured product requirements and backlog items.
- Partner with implementation and client success teams toidentifygaps betweenHealthRulesPayer provider data configuration and client-specific CMS compliance obligations, driving remediation through the product backlog.
- Define requirements for provider specialty, practicelocationand affiliation data management withinHealthRulesPayer to supportaccurateclaims routing,pricingand directory compliance.
- Serve as the embedded Medicareproviderdata SME, collaborating with engineering and QA to triage, prioritize and track provider data-related backlog items through resolution.
What you bring:
Required Qualifications
- 5+ years of product management or equivalent experience in healthcare payer operations, provider datamanagementor health plan network operations.
- Deep working knowledge of CMS Medicare FFS provider enrollment standards, NPI Registry requirements and PECOS enrollment and revalidation processes.
- Strong understanding of HIPAA provider data standards including taxonomy codes, specialtyclassificationand provider file transaction requirements (837/835 provider data elements).
- Experience translating CMS regulatory requirements into structured product requirements, userstoriesand acceptance criteria in an Agile development environment.
- Familiarity with provider directory accuracy obligations, CMS network adequacystandardsand provider credentialing workflows.
- Exceptional collaboration and communication skills with the ability to align engineering,implementationand client stakeholders around a shared provider data roadmap.
Preferred Qualifications
- Direct experience withHealthRulesPayer or similar core administrative processing (CAPS) platforms.
- Knowledge of CAQH ProView, PECOS and provider data exchange standards.
- Background in health plan provider relations, networkmanagementor credentialing operations in a SaaS payer technology environment.
- Experience with provider data governance frameworks and master data management (MDM) concepts in healthcare payer contexts.
Geographic Responsibility: Remote, US
Type of Employment:Full-time, permanent
FLSA Classification (USA Only):Exempt
Work Environment:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:
- The employeeis occasionally required tomove around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
- Work across multiple time zones in a hybrid or remote work environment.
- Long periodsof time sitting and/or standing in front of a computer using video technology.
- May require travel dependent on company needs.
The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skillsrequired.HealthEdgereserves the right tomodify, add, or remove duties and to assign otherdutiesas necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.Candidates maybe requiredto go through a pre-employment criminal background check.
**The annual US base salary range for this positionis $132,000 to $141,000. This salary range may cover multiple career levels atHealthEdge. Final compensation will bedeterminedduring the interview process and is based on a combination of factors including, but not limited to,your skills, experience,qualificationsand education.
