Job Description
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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