United States onlyOverview
Overview:
HealthEdge is seeking a Product Manager with deep expertise in Medicare Fee-for-Service enrollment operations and benefit design to join the HealthRules® Payer product team. In this role, you will own the product requirements that govern how health plans configure and administer Medicare FFS enrollment transactions, plan benefit packages and accumulator logic within the HealthRules Payer platform.
You will partner cross-functionally with engineering, QA, implementation and client success to ensure enrollment and benefit design capabilities consistently reflect CMS regulatory requirements – enabling our health plan clients to configure, launch and administer Medicare benefit structures with speed and confidence.
What You Will Own
The end-to-end product requirements for Medicare FFS enrollment workflows, plan benefit package configuration, accumulator logic and benefit limit enforcement within HealthRules® Payer – ensuring clients operate in continuous alignment with CMS enrollment mandates.
WHAT YOU'LL DO
Enrollment & Benefit Design
- Own product requirements for Medicare FFS enrollment workflows within HealthRules Payer, including enrollment transaction processing, plan benefit package configuration and enrollment reconciliation against CMS enrollment data.
- Define system behavior requirements for benefit design parameters including cost-sharing structures, benefit period logic, coverage exceptions and benefit limit enforcement as configured in HealthRules Payer.
- Drive accumulator configuration requirements for deductible, out-of-pocket maximum and benefit limit tracking across claim types, benefit periods and coordination of benefits scenarios within the HealthRules Payer accumulator framework.
- Evaluate CMS rulemaking cycles and annual benefit design updates to assess downstream impact on HealthRules Payer configuration and adjudication behavior, translating mandates into structured product requirements and acceptance criteria.
- Maintain a benefit design and enrollment change calendar aligned to CMS implementation timelines, sequencing HealthRules Payer releases to support client change readiness.
- Partner with implementation and client success teams to validate HealthRules Payer benefit configuration output against CMS enrollment records and member cost-sharing expectations, driving gap resolution through the product backlog.
- Serve as the embedded Medicare enrollment and benefit design SME, triaging and prioritizing regulatory-driven backlog items in collaboration with engineering and QA through resolution.
WHAT YOU BRING
Required Qualifications
- 5+ years of product management or equivalent experience in healthcare payer operations, Medicare FFS benefit administration or health plan enrollment processing.
- Deep working knowledge of Medicare FFS plan benefit package structure, CMS enrollment transaction requirements and annual benefit design update cycles.
- Experience translating CMS regulatory requirements into structured product requirements, user stories and acceptance criteria in an Agile development environment.
- Strong understanding of accumulator mechanics – deductible, out-of-pocket maximum and benefit limit tracking across multiple claim types and benefit periods.
- Familiarity with coordination of benefits (COB) rules and their interaction with Medicare FFS benefit design configurations.
- Exceptional collaboration and communication skills with the ability to align engineering, implementation and client stakeholders around a shared benefit design roadmap.
Preferred Qualifications
- Direct experience with HealthRules Payer or similar core administrative processing (CAPS) platforms.
- Knowledge of CMS enrollment reconciliation processes and MA plan benefit package submission requirements.
- Background in health plan implementation, benefit configuration or member services in a SaaS payer technology environment.
- Familiarity with 834 enrollment transaction standards and CMS enrollment data validation requirements.
ABOUT HEALTHEDGE
HealthEdge provides an integrated platform of solutions that enables health plans to converge their data and harness insights to improve outcomes. Our HealthRules Payer platform powers claims adjudication, payment accuracy and regulatory compliance for leading payers nationwide – enabling them to operate with agility as the regulatory landscape evolves.
We are a team of visionary, empathetic people who believe technology should remove friction from healthcare – not add to it. If you are passionate about using your expertise to build products that make a real difference for payers and the members they serve, we want to hear from you.
Geographic Responsibility: Remote, US
Type of Employment: Full-time, permanent
FLSA Classification (USA Only): Exempt
Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:
- The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
- Work across multiple time zones in a hybrid or remote work environment.
- Long periods of time sitting and/or standing in front of a computer using video technology.
- May require travel dependent on company needs.
The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.
HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.
**The annual US base salary range for this position is $132,000 to $141,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.
