Job Summary:
The Interoperability Product Owner is responsible for ensuring compliance with interoperability mandates and legal requirements, with a focus on the CMS-0057-F mandate and its expanding scope for payers. They will work closely with compliance teams, vendors, and external guidance/counsel to uphold CareSource's standards and commitment to excellence. This role serves as the single point of contact bridging compliance and business teams, translating CMS implementation guides and regulatory requirements into actionable requirements for clinical operations, membership operations, IT, Digital, and Customer Experience teams. Additionally, this role is responsible for ensuring CareSource meets HIPAA Transaction Code Set compliance for EDI and overseeing any current or future audits in this space and act as the main point of contact to translate and drive direction for the participating and implementation of TEFCA requirements and frameworks.
Essential Functions:
- Lead the oversight for any current or future compliance related audits and initiatives related to interoperability, active CMS audits (HIPAA Transaction Code Set compliance), ensuring CareSource meets all necessary compliance requirements.
- Actively participate in the Trusted Exchange Framework and Common Agreement (TEFCA) framework, anticipating proposed changes and their implications for data retrieval and sharing, and identifying opportunities to leverage TEFCA for payment processing, case coordination, and quality risk assessment.
- Collaborate with internal teams to establish data sharing agreements, ingestion contracts, and capabilities that meet compliance and operational needs.
- Serve as a single point of contact between the compliance and business teams to translate and align interoperability needs — drawn from CMS implementation guides, CMS-0057-F, and other regulatory sources — into actionable requirements.
- Educate internal teams on compliance impacts and operational changes necessary for successful implementation, including prior authorization process changes, payer-to-payer exchange requirements, and FHIR endpoint obligations.
- Oversee and vet vendor and internal builds to ensure compliance with CMS mandates, signing off on requirements and representing CareSource's compliance posture with states and other external entities. Write requirements, stories, solution artifacts as needed to drive execution.
- Drive alignment across business and IT teams on the build of FHIR endpoints (Patient Access, Provider Directory, Provider Access, Payer-to-Payer, Prior Auth API), including member identity matching, OAuth2-style security, logging, and uptime/SLA requirements.
- Ensure data readiness across claims, encounters, clinical data, and prior authorization information to meet CMS-0057-F timelines.
- Support prior authorization operational changes including tighter decision timeframes (72-hour urgent / 7 calendar day standard), improved denial communications, and public reporting metrics.
- Monitor and anticipate CMS's expanding mandate roadmap (2027, 2028, 2029) and identify opportunities to leverage interoperability investments beyond compliance, including prior authorization expansion and real-time processing improvements.
- Perform any other job related duties as requested.
Education and Experience:
- Bachelor's degree is required
- Master's degree is preferred
- Equivalent years of relevant work experience may be accepted in lieu of required education
- Five (5) years experience in healthcare interoperability, compliance, or regulatory environment required
Competencies, Knowledge and Skills:
- Strong analytical, decision making, and problem-solving skills
- Strong understanding of HIPAA regulations, Interoperability mandates, EDI, and CMS guidelines including CMS-0057-F
- Deep knowledge of FHIR APIs, OAuth2 security frameworks, and payer-to-payer exchange requirements
- Ability to interpret and apply CMS implementation guides and translate regulatory requirements into business and technical requirements
- Excellent project management skills and ability to juggle multiple priorities in a fast-paced environment
- Ability to work across and align multiple teams including clinical operations, membership, IT, Digital, and Customer Experience
- Strong communication and stakeholder management skills to bridge compliance and business teams
Licensure and Certification:
- None
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
- Travel is not typically required
Compensation Range:
$94,100.00 - $164,800.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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