[Remote] Consultant - Interoperability SME (CMS-0057-F)

Note: The job is a remote job and is open to candidates in USA. The client is a management and technology consulting firm supporting a state health care services agency. The role provides technical oversight for the agency’s CMS-0057-F interoperability program, reviewing implementation work, advising on decisions and risks, and guiding delivery of compliant FHIR APIs.

Responsibilities

• Act as the State's technical advisor on the CMS-0057-F program, reviewing implementation plans, designs, deliverables, and test results from development teams and vendors
• Assess build-versus-buy options and vendor proposals against CMS required standards, recommended implementation guides, security needs, scalability, and cost
• Review solution architecture end to end: FHIR server, API management and gateway, identity and authorization services, data feeds from claims, encounter, and prior authorization systems, and cloud hosting
• Identify risks, gaps, and schedule threats early; prepare clear risk, decision, and status briefings for State program and IT leadership
• Track readiness against federal compliance dates and advise on extension or exemption considerations available to state Medicaid fee-for-service programs
• Translate CMS-0057-F provisions into business rules, functional requirements, acceptance criteria, and traceability that development teams can build and test against
• Guide teams on required standards (FHIR R4.0.1, US Core, SMART App Launch, Bulk Data Access, OpenID Connect, USCDI) and recommended IGs (CARIN Blue Button, Da Vinci PDex, Plan-Net, US Drug Formulary, CRD, DTR, PAS)
• Oversee prior authorization automation and its business rules: covered items lists, documentation requirements, request and response, FHIR and X12 278 choices, decision timeframes, and denial reasons
• Review consent and permission models, including Payer-to-Payer opt-in, Provider Access opt-out, provider attribution, and plain-language member education
• Validate security and privacy controls: OAuth 2.0, OpenID Connect, SMART backend services, third-party app registration, and HIPAA safeguards
• Evaluate data exchange design for claims, encounter, USCDI, and prior authorization data, including bulk data access, five-year lookback, data quality, and performance at scale
• Oversee reporting obligations, including Patient Access API usage metrics to CMS and publicly posted prior authorization metrics
• Partner with State staff, architects, security leads, and vendors; bring structure to open-ended questions by framing decisions and drafting options
• Share work early and often through drafts, reviews, and short check-ins rather than end-of-sprint reveals
• Oversee implementation services and cloud operations readiness, including environments, release management, monitoring, and transition to ongoing operations

Skills

• 8+ years in health IT, including 5+ years of hands-on HL7 FHIR API experience
• Hands-on CMS-0057-F implementation experience, with direct work on its FHIR APIs: Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization
• Consulting firm background delivering health IT programs for public sector clients
• Working knowledge of the CMS required standards and recommended FHIR implementation guides, including the Da Vinci prior authorization guides (CRD, DTR, PAS)
• Experience overseeing technical work by vendors and development teams: architecture, API design, test results, and delivery plans
• Solid grasp of healthcare API security and consent: OAuth 2.0, OpenID Connect, SMART on FHIR, and HIPAA
• Ability to brief senior state leaders in plain language and to produce clear written decision and risk documents
• State Medicaid agency experience, ideally on Medicaid Enterprise Systems (MES) modernization, IV&V, and CMS certification work
• Experience with California Medi-Cal programs and California health and human services agencies
• Oversight of Medicaid managed care plan compliance with federal interoperability requirements
• Prior CMS-9115-F experience (Patient Access and Provider Directory APIs)
• Cloud FHIR services and API management platforms (Azure, AWS, Google Cloud); HL7 FHIR certification; PMP

Benefits

• Remote (U.S. based)

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