Overview:

HealthEdge is seeking a Product Manager with deep expertise in CMS Medicare Fee-for-Service provider data standards to join the HealthRules® Payer product team. In this role, you will own the product requirements that define how health plans onboard, validate, maintain and operationalize provider data within the HealthRules Payer platform – ensuring alignment with CMS enrollment, credentialing and revalidation mandates. 

You will partner cross-functionally with engineering, QA, implementation and client success to ensure HealthRules Payer provider data capabilities are accurate, compliant and scalable – empowering our health plan clients to meet provider directory accuracy obligations and support clean claims adjudication. 

What You Will Own:

The product requirements governing provider data standards, NPI validation, taxonomy classification, PECOS alignment and provider directory accuracy obligations within HealthRules® Payer – ensuring health plan clients meet CMS provider data integrity mandates. 

What you'll do:

Provider Data Management 

• Develop HealthRules Payer product requirements supporting CMS Medicare FFS provider data standards, including NPI validation, taxonomy classification, specialty mapping and provider file maintenance aligned to HIPAA standard transaction requirements. 

• Ensure HealthRules Payer provider configuration capabilities align with CMS enrollment, credentialing and revalidation mandates – including requirements for PECOS data alignment and provider directory accuracy obligations. 

• Define requirements for provider data ingestion and maintenance workflows within HealthRules Payer, including automated validation rules, exception handling and provider data reconciliation processes. 

• Translate CMS provider data regulatory updates – including PECOS revalidation cycles, taxonomy code set changes and NPI Registry alignment requirements – into structured product requirements and backlog items. 

• Partner with implementation and client success teams to identify gaps between HealthRules Payer provider data configuration and client-specific CMS compliance obligations, driving remediation through the product backlog. 

• Define requirements for provider specialty, practice location and affiliation data management within HealthRules Payer to support accurate claims routing, pricing and directory compliance. 

• Serve as the embedded Medicare provider data SME, collaborating with engineering and QA to triage, prioritize and track provider data-related backlog items through resolution. 

What you bring:

Required Qualifications 

• 5+ years of product management or equivalent experience in healthcare payer operations, provider data management or health plan network operations. 

• Deep working knowledge of CMS Medicare FFS provider enrollment standards, NPI Registry requirements and PECOS enrollment and revalidation processes. 

• Strong understanding of HIPAA provider data standards including taxonomy codes, specialty classification and provider file transaction requirements (837/835 provider data elements). 

• Experience translating CMS regulatory requirements into structured product requirements, user stories and acceptance criteria in an Agile development environment. 

• Familiarity with provider directory accuracy obligations, CMS network adequacy standards and provider credentialing workflows. 

• Exceptional collaboration and communication skills with the ability to align engineering, implementation and client stakeholders around a shared provider data roadmap. 

 Preferred Qualifications 

• Direct experience with HealthRules Payer or similar core administrative processing (CAPS) platforms. 

• Knowledge of CAQH ProView, PECOS and provider data exchange standards. 

• Background in health plan provider relations, network management or credentialing operations in a SaaS payer technology environment. 

• Experience with provider data governance frameworks and master data management (MDM) concepts in healthcare payer contexts. 

ABOUT HEALTHEDGE 

HealthEdge provides an integrated platform of solutions that enables health plans to converge their data and harness insights to improve outcomes. Our HealthRules Payer platform powers claims adjudication, payment accuracy and regulatory compliance for leading payers nationwide – enabling them to operate with agility as the regulatory landscape evolves. 

 We are a team of visionary, empathetic people who believe technology should remove friction from healthcare – not add to it. If you are passionate about using your expertise to build products that make a real difference for payers and the members they serve, we want to hear from you. 

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

FLSA Classification (USA Only): Exempt 

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:  

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

#LI-Remote 

**The annual US base salary range for this position is $132,000 to $141,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.