FHIR (Subject matter Expert)

The FHIR Subject Matter Expert (SME) is a highly versatile technical and business "utility player" crucial to driving compliance and implementation for the CMS-0057-F and CMS-0062-P Prior Authorization rules. This role sits at the intersection of regulatory analysis, technical architecture, and data engineering, translating complex federal rules and Da Vinci Implementation Guides (IGs) into actionable system requirements, robust FHIR payloads, and rigorous testing frameworks.

Key Responsibilities

• Regulatory Analysis: Analyze CMS rules and Da Vinci IGs (CRD, DTR, PAS) to extract technical specifications. Translate these into business rules, Excel technical specs, and developer-ready documentation.
• Data Mapping: Map complex FHIR resources, codesets, and datatypes directly to canonical databases. Use SQL to query and verify database schemas against FHIR profiles.
• Payload Synthesis & Validation: Create both valid and intentionally errant FHIR payloads for testing. Use validation tools (such as validator.fhir.org and Inferno) to diagnose and resolve FHIR errors, warnings, and alerts.
• Testing & Quality Assurance: Design comprehensive test plans for all target APIs, generate test payloads for all QA phases, and provide hands-on support to testing teams.

Required Technical Skillset

• Da Vinci IGs & Profiles: Hands-on experience with Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS). Familiarity with US Core (USCDI), HRex, and the PriorAuth-specific Coverage-Information extension.
• FHIR Modeling Proficiency: Strong understanding of cardinality, MustSupport elements, references, complex/simple datatypes, value sets, code sets, slicing, extensions, constraints, and Bundles.
• Structured Data Capture (SDC): Knowledge of SDC Hooks, Cards, System Actions, and Prefetch concepts.
• Database & Tools: Proficiency in SQL and experience using FHIR validation tools (Inferno, validator.fhir.org).