Healthcare Interoperability Subject Matter Expert (SME)

Role: Healthcare Interoperability Subject Matter Expert (SME)

Location: Remote

Duration: Long Term Contract

Job Description Healthcare Interoperability Subject Matter Expert (SME)

Position Summary

We are seeking an experienced Healthcare Interoperability Subject Matter Expert (SME) with deep expertise in healthcare data exchange, CMS interoperability mandates, FHIR APIs, EDI transactions, and enterprise integration technologies. The ideal candidate will possess strong functional and technical knowledge of healthcare interoperability standards and payer ecosystems, supporting initiatives related to API enablement, real-time integrations, batch processing, and regulatory compliance.

This role requires a strong understanding of CMS interoperability requirements, healthcare data exchange standards, enterprise integration architecture, and payer systems.

Key Responsibilities

• Serve as the Subject Matter Expert for healthcare interoperability initiatives across payer platforms.
• Provide expertise on CMS Interoperability and Patient Access regulations, including recent CMS guidelines and regulatory updates.
• Support the design, implementation, and enhancement of healthcare interoperability solutions based on HL7 FHIR standards.
• Collaborate with business, architecture, development, and integration teams to define interoperability requirements and recommend best practices.
• Review solution designs to ensure compliance with CMS mandates, HIPAA requirements, and healthcare interoperability standards.
• Provide guidance on API security, consent management, authentication, and authorization mechanisms.
• Support enterprise integration initiatives involving real-time, near real-time, and batch data exchanges.
• Work closely with internal stakeholders and external trading partners to ensure seamless healthcare data exchange.
• Participate in solution reviews, requirement analysis, testing support, and production issue resolution.

Required Subject Matter Expertise

Healthcare Interoperability

Strong knowledge and hands-on experience with:

• Patient Access API
• HL7 FHIR-based APIs
• Secure member access to claims, encounter, and clinical data
• Third-party application integration
• Provider Directory API
• Publishing provider directories using standardized FHIR formats
• Provider demographics
• Network participation
• Provider specialties and contact information
• Payer-to-Payer Data Exchange
• Member data portability between health plans
• Historical clinical and claims data exchange
• CMS interoperability requirements
• Security & Consent Management
• OAuth 2.0
• OpenID Connect (preferred)
• Authentication and authorization
• Consent management
• Secure API access

Healthcare Standards

Required knowledge of:

• HL7 FHIR
• Healthcare APIs
• EDI Transactions (834, 835, 837, 270/271, 276/277)
• HIPAA standards
• Healthcare payer workflows
• Provider and member data exchange

CMS Knowledge

Strong understanding of:

• CMS Interoperability and Patient Access Final Rule
• CMS interoperability guidelines
• Current and emerging CMS regulatory changes
• Healthcare data exchange compliance requirements

Enterprise Integration Experience

Experience working with:

Real-Time & Near Real-Time Integrations

• Web Services
• REST APIs
• Message Queue architecture
• Enterprise Service Bus (ESB)

Knowledge of IBM integration technologies including:

• IBM DataPower
• IBM Integration Bus (IIB)
• IBM WebSphere MQ (WMQ)
• WebSphere Service Registry and Repository (WSRR)
• IBM DB2

Batch Processing

Experience supporting batch integrations using Managed File Transfer Services (MFTS), including:

• Batch file production and consumption
• Trading partner integrations
• Healthcare enrolment and eligibility exchanges
• Member data processing
• HMO 834 Enrolment Updates
• Integration with Medicaid Enterprise Systems (MES) and other external partners

Required Qualifications

• Bachelor s degree in computer science, Information Systems, Healthcare Informatics, or a related field.
• 8+ years of experience in healthcare payer systems, healthcare integration, or interoperability.
• Strong experience implementing or supporting healthcare interoperability solutions.
• Hands-on knowledge of HL7 FHIR APIs and healthcare integration standards.
• Experience with EDI healthcare transactions.
• Understanding of CMS interoperability regulations and healthcare compliance.
• Experience working with enterprise integration platforms and middleware technologies.
• Strong analytical, communication, and stakeholder management skills.

Preferred Qualifications

• Experience with Medicaid or Medicare programs.
• Experience working with enterprise healthcare integration platforms.
• Knowledge of cloud-based API management platforms.
• Familiarity with Agile delivery methodologies.
• Experience supporting large-scale healthcare transformation initiatives.

Desired Skills

• Healthcare Interoperability
• HL7 FHIR
• Patient Access API
• Provider Directory API
• Payer-to-Payer Data Exchange
• CMS Interoperability Rules
• EDI Transactions
• OAuth 2.0
• REST APIs
• Enterprise Service Bus (ESB)
• IBM DataPower
• IBM Integration Bus (IIB)
• WebSphere MQ
• WSRR
• DB2
• Managed File Transfer (MFT)
• Healthcare Payer Systems
• HIPAA Compliance
• Healthcare Integration Architecture