Product Manager, Medicare Provider Data Management

📋 Description

• Create product specifications for the HealthRules Payer system that adhere to CMS Medicare FFS provider data standards, encompassing NPI validation, taxonomy classification, specialty mapping, and the maintenance of provider files in compliance with HIPAA standard transaction requirements.

• Ensure that the provider configuration features in HealthRules Payer are in line with CMS mandates regarding enrollment, credentialing, and revalidation, including the alignment of PECOS data and the obligations for provider directory accuracy.

• Establish requirements for workflows related to provider data ingestion and maintenance within HealthRules Payer, integrating automated validation rules, exception handling, and provider data reconciliation processes.

• Convert CMS updates on provider data regulations, such as PECOS revalidation cycles, changes to taxonomy code sets, and requirements for NPI Registry alignment, into organized product requirements and items for the backlog.

• Collaborate with implementation and client success teams to pinpoint discrepancies between HealthRules Payer provider data configurations and specific CMS compliance requirements for clients, driving corrective actions through the product backlog.

• Outline requirements for managing provider specialty, practice location, and affiliation data within HealthRules Payer to ensure precise claims routing, pricing, and directory compliance.

• Act as the embedded subject matter expert (SME) for Medicare provider data, working closely with engineering and QA teams to prioritize, manage, and resolve provider data-related backlog items.

⛳️ Requirements

• A minimum of 5 years of experience in product management or equivalent roles within healthcare payer operations, provider data management, or health plan network operations.

• Extensive knowledge of CMS Medicare FFS provider enrollment standards, NPI Registry requirements, and the processes for PECOS enrollment and revalidation.

• Strong grasp of HIPAA provider data standards including taxonomy codes, specialty classifications, and transaction requirements for provider files (837/835 provider data elements).

• Proven experience in translating CMS regulatory requirements into structured product specifications, user stories, and acceptance criteria within an Agile development framework.

• Familiarity with obligations for provider directory accuracy, CMS network adequacy standards, and workflows related to provider credentialing.

• Outstanding collaboration and communication skills, with the ability to unify engineering, implementation, and client stakeholders around a common provider data roadmap.

🏝️ Benefits

• HealthEdge offers an integrated suite of solutions that empowers health plans to unify their data and leverage insights to enhance outcomes.

• Our HealthRules Payer platform facilitates claims adjudication, ensures payment accuracy, and maintains regulatory compliance for leading payers across the nation, allowing them to adapt swiftly as the regulatory environment shifts.

• We are a group of forward-thinking, compassionate individuals who believe that technology should eliminate obstacles in healthcare rather than create them.

• If you are enthusiastic about utilizing your expertise to develop products that genuinely impact payers and the members they support, we would love to hear from you.