Product Manager, Medicare Provider Data Management

HealthEdge

3d•Remote

About The Position

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.

Requirements

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.

Nice To Haves

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.

Responsibilities

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.