Interoperability Product Owner

CareSource•Dayton, OH

2d•$94,100 - $164,800•Onsite

About The Position

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. This role leads 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.

Requirements

Bachelor's degree is required
Five (5) years experience in healthcare interoperability, compliance, or regulatory environment required
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

Nice To Haves

Master's degree is preferred

Responsibilities

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.