Healthcare Interoperability & Compliance SME

Introduction:

We are seeking a Healthcare Interoperability Subject Matter Expert (SME) to support regulatory compliance and guide implementation teams in healthcare data exchange solutions. The SME will:

Responsibilities:

• Serve as SME for X12 278 Prior Authorization workflows (inbound/outbound transactions, acknowledgments, error handling).
• Provide expert guidance on HL7 FHIR standards and CMS regulations.
• Ensure compliance with CMS-57F mandates, including prior authorization requirements and interoperability timelines.
• Translate CMS regulations into actionable technical and functional requirements.
• Participate in design reviews, architecture discussions, and audits.
• Review mapping documents, data models, and integration flows for compliance and accuracy.
• Collaborate with product owners, architects, developers, QA, and client stakeholders.
• Provide guidance on best practices for interoperability, security, and data governance.
• Support documentation, compliance artifacts, and knowledge transfer activities.

Requirements:

• Deep hands-on knowledge of X12 EDI 278 Prior Authorization transactions
• Strong experience with HL7 FHIR (R4 preferred), APIs, and implementation guides
• Proven expertise in CMS-57F compliance and interoperability mandates
• Understanding of payer-provider workflows, utilization management, and prior authorization processes
• Experience with EHR/EMR systems, clearinghouses, and payer platforms
• Ability to translate CMS regulations into technical and functional requirements
• Excellent communication skills for technical and non-technical stakeholders