Product Manager, Medicare Provider Data Management

HealthEdge is seeking a Product Manager with expertise in CMS Medicare Fee-for-Service provider data standards to join their HealthRules® Payer product team. The role involves owning product requirements for provider data management, ensuring compliance with CMS mandates, and collaborating cross-functionally to enhance data capabilities for health plan clients.

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

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
• 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