OverviewOverview:
HealthEdge is seeking a Product Manager to own the CMS integration strategy and API connectivity roadmap for HealthRules4 Payer. As federal programs expand their digital infrastructure 6 froma0MACProa0and the CMS Data Services Hub to FHIR-based interoperability mandates and real-time eligibility connectivity 6 health plansa0requirea0a platform that integrates reliably, securely and in full compliance with CMS technical specifications.a0
In this role, you will define,a0prioritizea0and drive the product requirements that govern howa0HealthRulesa0Payer connects to CMS federal systems, third-party payera0platformsa0and health plan operational infrastructure. You will own the integration catalog, API design standards, connectora0frameworka0and the requirements that ensure every CMS-mandated data exchange isa0accurate,a0auditablea0and aligned to current CMS technical specifications and certification requirements.a0
a0You will partner closely with engineering, solution architecture,a0implementationa0and client success teams to ensurea0HealthRulesa0Payer integrations are production-grade, scalable and supportable 6 and that health plan clients can onboard, certify anda0operatea0CMS integrations with minimal friction and maximum confidence.a0
What You Will Owna0
The end-to-end integration product strategy fora0HealthRulesa0Payer 6 spanning CMS federal system connections, standard API and connector frameworks, FHIR-based interoperability, EDI/batch data exchange and the certification and compliance requirements that govern each integration domain.a0
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CMS INTEGRATION LANDSCAPEa0
The following CMS federal systemsa0representa0the core integration surface area this role owns withina0HealthRulesa0Payer. The PMa0is responsible fora0defining anda0maintaininga0product requirements across all active and planned integrations within this catalog.
WHAT YOU'LL DOa0
CMS Integration Strategy & Roadmapa0
- Own anda0maintaina0thea0HealthRulesa0Payer CMS integration catalog 6 defining the current state of each integration, its certification status, data exchange scope, technical specificationa0versiona0and planned roadmap investments.a0
- Develop and drive the multi-year CMS integration roadmap fora0HealthRulesa0Payer, aligning integration investments with CMS regulatory milestones, federal rulemakinga0timelinesa0and client demand signals.a0
- Evaluate new and evolving CMS system requirements 6 including FHIR API mandates under the Interoperability and Prior Authorization Final Rule (CMS-0057-F), CMS Data Services Hub enhancements anda0MACPro/MACFina0modernization efforts 6 and translate obligations intoa0HealthRulesa0Payer integration requirements.a0
- Define the integration architecture principles fora0HealthRulesa0Payer,a0establishinga0standards for API design, connector reuse, payload validation, errora0handlinga0and integration observability in partnership with engineering and solution architecture.a0
- Monitor CMS technical bulletin releases, data services hub announcements and federal system decommission or migration notices, proactively assessing impact ona0HealthRulesa0Payer integration continuity and driving necessary updates through the product backlog.a0
a0API Design & Connector Frameworka0
- Own product requirements for thea0HealthRulesa0Payer API layer 6 defining RESTful API contracts, FHIR R4 resource profiles, authentication standards (OAuth 2.0, SMART on FHIR) and versioning policies that govern how internal and external systems connect toa0HealthRulesa0Payer.a0
- Define requirements for a reusable connector framework withina0HealthRulesa0Payer that enables health plan clients to configure, activate anda0monitora0CMS system integrations without custom development 6 reducing implementation time and ongoing maintenance burden.a0
- Establish API design standards fora0HealthRulesa0Payer outbound and inbound integrations, including payload schema definitions, error code taxonomy, retry logic, ratea0limitinga0and API lifecycle governance.a0
- Partner with engineering to define integration testing requirements 6 including unit, contract,a0regressiona0and end-to-end testing protocols 6 ensuring each CMS integrationa0maintainsa0specification compliance acrossa0HealthRulesa0Payer release cycles.a0
- Define product requirements for an integration monitoring and observability capability withina0HealthRulesa0Payer, enabling health plan clients anda0HealthEdgea0operations teams to track integration health, transaction volumes, errora0ratesa0and SLA performance in real time.a0
a0FHIR & Interoperability Compliancea0
- Own product requirements fora0HealthRulesa0Payer FHIR R4 API capabilities mandated under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), including the Patient Access API, Provider Directory API, Payer-to-Payera0APIa0and Prior Authorization API.a0
- Translate Da Vinci Implementation Guide requirements 6 includinga0PDex, PCDE, PAS, CRD and DTR 6 intoa0HealthRulesa0Payer FHIR API and integration configuration requirements, sequenced against CMS compliance effective dates.a0
- Define requirements for FHIR resource mapping betweena0HealthRulesa0Payer clinical and administrative data models and CMS-required FHIR profiles, ensuring data element completeness, terminology binding accuracy and conformance to US Core and CARIN IG standards.a0
- Managea0HealthRulesa0Payer FHIR certification requirements, coordinating with engineering and QA to maintain ONC certification alignment and CMS API compliance posture across product releases.a0
- Partner with implementation and client success teams to support health plan client FHIR API onboarding, third-party application registrationa0workflowsa0and payer-to-payer data exchange activation withina0HealthRulesa0Payer.a0
a0EDI & Batch Integration Managementa0
- Definea0HealthRulesa0Payer integration requirements for CMS EDI gateway connectivity, including EDISS/Medicare EDI transaction submission, acknowledgmenta0processinga0and error resolution workflows for all HIPAA ASC X12 transaction sets.a0
- Own product requirements for batch data exchange integrations with CMS systems includinga0MARxa0(Part D enrollment anda0TrOOP), CMS IDR/CCW (claims data access), PECOS (provider data feeds) and HPMS (plana0data submissions).a0
- Define requirements fora0HealthRulesa0Payer file format validation,a0transformationa0and routing capabilities to support CMS batch submission standards across EDI, fixed-width,a0CSVa0and XML payload formats.a0
- Ensurea0HealthRulesa0Payer integration requirements address CMS data submission deadlines, file naming conventions, submission acknowledgmenta0workflowsa0and error resubmission processes for all batch-based CMS integrations.a0
a0Integration Certification & Compliancea0
- Own product requirements for CMS integration certification and testing processes applicable toa0HealthRulesa0Payer 6 including CMS Data Services Hub certification, Medicare EDI testing, FHIR API conformance testing and applicable ONC certification criteria.a0
- Maintaina0a CMS integration compliancea0registera0fora0HealthRulesa0Payer, tracking certification status, specification version currency, knowna0gapsa0and remediation timelines for each integration in the catalog.a0
- Partner with regulatory and compliance teams to interpret CMS technical companion guides, system interfacea0specificationsa0and federal notice of proposed rulemaking (NPRM) technical appendices, translating obligations intoa0HealthRulesa0Payer integration backlog items.a0
- Support health plan client procurement and compliance reviews by providinga0accuratea0HealthRulesa0Payer integration capability documentation, certificationa0evidencea0and technical specification alignment statements.a0
a0Cross-Functional Delivery & Client Enablementa0
- Serve as the primary integration subject matter expert fora0HealthRulesa0Payer, partnering with engineering, solution architecture, implementation, client success and EDI operations teams to triage, prioritize and resolve integration-related product gaps.a0
- Define integration onboarding requirements fora0HealthRulesa0Payer, ensuring health plan clients can activate,a0configurea0and test CMS integrations within a structured, documented implementation framework.a0
- Develop integration product documentation 6 including API reference guides, connector configurationa0specificationsa0and CMS integration setup runbooks 6 in collaboration with technical writing and implementation teams.a0
- Collaborate with client success and implementation teams to capture integration feedback, escalate productiona0issuesa0and prioritize integration enhancements that reduce client operational friction and improve CMS data exchange reliability.a0
WHAT YOU BRINGa0
Required Qualificationsa0
- 5+ years of product management or equivalent experience in healthcare payer technology, health ITa0interoperabilitya0or CMS federal program systems integration.a0
- Demonstrateda0expertisea0in CMS federal system integrations 6 including firsthand experience with one or more of the following: CMS Data Services Hub,a0MARx, HPMS, PECOS, CMS FHIR APIs ora0MACPro/MACFin.a0
- Deep working knowledge of FHIR R4 standards, US Core Implementation Guides, Da Vinci use case profiles (PDex, PAS, CRD, DTR) and CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requirements.a0
- Strong understanding of HIPAA ASC X12 EDI transaction standards 6 including 837, 835, 270/271, 276/277, 278 and 834 6 and CMS EDI gateway submission and certification requirements.a0
- Experience defining RESTful API product requirements, including API contract design, OAuth 2.0/SMART on FHIR authentication, payload schemaa0standardsa0and API versioning governance.a0
- Proven ability to translate complex CMS technical specifications, companion guides and federal rulemaking into structured product requirements and engineering-ready backlog items in an Agile environment.a0
- Exceptional communication and stakeholder alignment skills 6 you can bridge the gap between CMS technical specification language and the engineering, implementation and client audiences who act on it.a0
a0Preferred Qualificationsa0
- Direct experience witha0HealthRulesa0Payer or similar core administrative processing (CAPS) platforms and their integration architecture.a0
- Familiarity with ONC Health IT certification criteria, CMS API certificationa0requirementsa0and SMART App Launch framework standards.a0
- Knowledge of CMS Innovation Center APM participation data exchange requirements and quality reporting integrations.a0
- Experience with integration platform tooling 6 including MuleSoft, Azure API Management, AWS APIa0Gatewaya0or comparable enterprise integration middleware.a0
- Background in healthcare payer EDI operations, solutiona0architecturea0or system implementation in a SaaS technology environment.a0
- Understanding of CMS data governance requirements, PHI security standards under HIPAA and CMS data use agreement obligations applicable to federal data integrations.a0
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:a0
- The employeea0is occasionally required toa0move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.a0
- Work across multiple time zones in a hybrid or remote work environment.a0
- Long periodsa0of time sitting and/or standing in front of a computer using video technology.a0
- May require travel dependent on company needs.a0
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