Product Manager, CMS Integrations

🕒 5 days ago

🇺🇸 United States – Remote

💵 $132k - $141k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

✅ Product Manager

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

⚕️ Healthcare Insurance

☁️ SaaS

💳 Fintech

Healthcare Insurance • SaaS • Fintech

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• Own and maintain the HealthRules Payer CMS integration catalog – defining the current state of each integration, its certification status, data exchange scope, technical specification version and planned roadmap investments. • Develop and drive the multi-year CMS integration roadmap for HealthRules Payer, aligning integration investments with CMS regulatory milestones, federal rulemaking timelines and client demand signals. • Evaluate new and evolving CMS system requirements – including FHIR API mandates under the Interoperability and Prior Authorization Final Rule (CMS-0057-F), CMS Data Services Hub enhancements and MACPro / MACFin modernization efforts – and translate obligations into HealthRules Payer integration requirements. • Define the integration architecture principles for HealthRules Payer, establishing standards for API design, connector reuse, payload validation, error handling and integration observability in partnership with engineering and solution architecture. • Monitor CMS technical bulletin releases, data services hub announcements and federal system decommission or migration notices, proactively assessing impact on HealthRules Payer integration continuity and driving necessary updates through the product backlog. • Own product requirements for the HealthRules Payer API layer – 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 to HealthRules Payer. • Define requirements for a reusable connector framework within HealthRules Payer that enables health plan clients to configure, activate and monitor CMS system integrations without custom development – reducing implementation time and ongoing maintenance burden. • Establish API design standards for HealthRules Payer outbound and inbound integrations, including payload schema definitions, error code taxonomy, retry logic, rate limiting and API lifecycle governance. • Partner with engineering to define integration testing requirements – including unit, contract, regression and end-to-end testing protocols – ensuring each CMS integration maintains specification compliance across HealthRules Payer release cycles. • Define product requirements for an integration monitoring and observability capability within HealthRules Payer, enabling health plan clients and HealthEdge operations teams to track integration health, transaction volumes, error rates and SLA performance in real time. • Own product requirements for HealthRules Payer 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-Payer API and Prior Authorization API. • Translate Da Vinci Implementation Guide requirements – including PDex, PCDE, PAS, CRD and DTR – into HealthRules Payer FHIR API and integration configuration requirements, sequenced against CMS compliance effective dates. • Define requirements for FHIR resource mapping between HealthRules Payer 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. • Manage HealthRules Payer FHIR certification requirements, coordinating with engineering and QA to maintain ONC certification alignment and CMS API compliance posture across product releases. • Partner with implementation and client success teams to support health plan client FHIR API onboarding, third-party application registration workflows and payer-to-payer data exchange activation within HealthRules Payer. • Define HealthRules Payer integration requirements for CMS EDI gateway connectivity, including EDISS/Medicare EDI transaction submission, acknowledgment processing and error resolution workflows for all HIPAA ASC X12 transaction sets. • Own product requirements for batch data exchange integrations with CMS systems including MARx (Part D enrollment and TrOOP), CMS IDR/CCW (claims data access), PECOS (provider data feeds) and HPMS (plan data submissions). • Define requirements for HealthRules Payer file format validation, transformation and routing capabilities to support CMS batch submission standards across EDI, fixed-width, CSV and XML payload formats. • Ensure HealthRules Payer integration requirements address CMS data submission deadlines, file naming conventions, submission acknowledgment workflows and error resubmission processes for all batch-based CMS integrations. • Own product requirements for CMS integration certification and testing processes applicable to HealthRules Payer – including CMS Data Services Hub certification, Medicare EDI testing, FHIR API conformance testing and applicable ONC certification criteria. • Maintain a CMS integration compliance register for HealthRules Payer, tracking certification status, specification version currency, known gaps and remediation timelines for each integration in the catalog. • Partner with regulatory and compliance teams to interpret CMS technical companion guides, system interface specifications and federal notice of proposed rulemaking (NPRM) technical appendices, translating obligations into HealthRules Payer integration backlog items. • Serve as the primary integration subject matter expert for HealthRules Payer, partnering with engineering, solution architecture, implementation, client success and EDI operations teams to triage, prioritize and resolve integration-related product gaps. • Define integration onboarding requirements for HealthRules Payer, ensuring health plan clients can activate, configure and test CMS integrations within a structured, documented implementation framework. • Develop integration product documentation – including API reference guides, connector configuration specifications and CMS integration setup runbooks – in collaboration with technical writing and implementation teams. • Collaborate with client success and implementation teams to capture integration feedback, escalate production issues and prioritize integration enhancements that reduce client operational friction and improve CMS data exchange reliability.

🎯 Requirements

• 5+ years of product management or equivalent experience in healthcare payer technology, health IT interoperability or CMS federal program systems integration. • Demonstrated expertise in CMS federal system integrations – including firsthand experience with one or more of the following: CMS Data Services Hub, MARx, HPMS, PECOS, CMS FHIR APIs or MACPro / MACFin. • 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. • Strong understanding of HIPAA ASC X12 EDI transaction standards – including 837, 835, 270/271, 276/277, 278 and 834 – and CMS EDI gateway submission and certification requirements. • Experience defining RESTful API product requirements, including API contract design, OAuth 2.0/SMART on FHIR authentication, payload schema standards and API versioning governance. • 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. • Exceptional communication and stakeholder alignment skills – you can bridge the gap between CMS technical specification language and the engineering, implementation and client audiences who act on it.

🏖️ Benefits

• Health insurance • 401(k) matching • Flexible work hours • Paid time off • Remote work options