Healthcare Interoperability & Compliance SME (X...
Must Have FHIR EDI 278, CMS 57 Experience Healthcare Interoperability & Compliance SME (X12 278 / FHIR / CMS-57F) Role Summary We are seeking a Healthcare Interoperability Subject Matter Expert (SME) with strong hands-on experience in X12 278 transactions, HL7 FHIR standards, and CMS-57F compliance. The SME will support regulatory compliance, guide implementation teams, and ensure healthcare data exchange solutions align with CMS and industry standards. Key Responsibilities • Serve as SME for X12 278 (Prior Authorization) workflows, including inbound/outbound transactions, acknowledgments, and error handling. • Provide expert guidance on HL7 FHIR standards, including FHIR resources, APIs, profiles, and implementation guides relevant to CMS regulations. • Ensure solution compliance with CMS-57F mandates, including Prior Authorization requirements and interoperability timelines. • Interpret CMS regulations and translate them into technical and functional requirements for delivery teams. • Support design reviews, architecture discussions, and solution validation to ensure regulatory adherence. • Collaborate with product owners, architects, developers, QA, and client stakeholders. • Review mapping documents, data models, and integration flows for compliance and accuracy. • Assist with client discussions, audits, and regulatory readiness assessments. • Provide guidance on best practices for healthcare interoperability, security, and data governance. • Support documentation, compliance artifacts, and knowledge transfer activities. Required Skills & Experience • 8+ years of experience in healthcare IT with strong domain expertise. • Deep hands-on knowledge of X12 EDI, specifically 278 Prior Authorization transactions. • Strong experience with HL7 FHIR (R4 preferred), FHIR APIs, and implementation guides. • Proven experience supporting CMS-57F compliance and CMS interoperability mandates. • Understanding of payer-provider workflows, utilization management, and prior authorization processes. • Experience working with EHR/EMR systems, clearinghouses, and payer platforms. • Ability to translate regulatory requirements into technical and functional solutions. • Excellent communication skills to work with both technical and non-technical stakeholders. Preferred Qualifications • Experience with CMS Interoperability and Prior Authorization Final Rule implementations. • Familiarity with OAuth 2.0, SMART on FHIR, and healthcare security standards. • Exposure to cloud-based healthcare platforms (Azure, AWS, GCP). • Experience supporting large payer or healthcare transformation programs. • Prior experience in client-facing SME or consulting roles.
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