Healthcare Interoperability; FHIR Analyst - Remote

Interoperability Implementation & Requirements Analysis

• Gather, document, and validate business and technical requirements for interoperability solutions such as FHIR APIs, Member Access APIs, Provider Directory APIs, Payer-to-Payer Data Exchange, and Prior Authorization APIs.
• Analyze CMS/ONC regulations (e.g., CMS Interoperability & Patient Access Rule, CMS Prior Authorization Rule, TEFCA-related requirements) and translate them into actionable system requirements.
• Support gap analysis for existing payer systems (claims, clinical data, provider, member, authorization) to determine interoperability readiness.

• Develop functional specifications, user stories, acceptance criteria, and process workflows for interoperability implementations.
• Work with architects and engineers to define data mapping, transformation logic, and API interaction models aligned with HL7 FHIR standards.
• Ensure solutions integrate effectively with enterprise systems such as claims adjudication, enrollment, provider management, UM/PA, care management, and data warehouses.

• Perform data profiling and mapping for clinical and administrative datasets (e.g., EDI 837/835, 270/271, CCDA, FHIR resources).
• Support test case development, test planning, and execution for API validation, edge‑case handling, and compliance testing.
• Ensure data accuracy, completeness, and compliance with security and privacy standards (HIPAA, PHI/PII handling).

• Serve as the liaison between business stakeholders and technical teams, ensuring alignment on requirements, scope, and delivery timelines.
• Participate in sprint planning, backlog grooming, and solution demonstrations as part of Agile/Scrum teams.
• Provide subject matter expertise (SME) on payer workflows such as claims processing, member onboarding, provider data management, care management, and prior authorizations.

• 8-10 years of experience as a Business Analyst or Business Systems Analyst in the healthcare payer domain.
• Strong understanding of FHIR standards, HL7, EDI transactions, and healthcare information exchange models.
• Hands‑on experience with interoperability implementations, preferably CMS‑mandated FHIR APIs or payer modernization initiatives.
• Working knowledge of healthcare payer systems and processes (benefits, claims, enrollment, provider data, UM/PA).
• Experience writing business, functional, and technical specs, data mapping documents, and business process flows.
• Strong analytical, problem‑solving, and communication skills.