QA(FHIR)-Remote

Requirements

Currently, this revolves around CMS-0057-F and, now, CMS-0062-P rules for prior authorization.

Documents and Rules

Read full CMS rules and extract technical detail

Master Da Vinci Implementation Guides (IGs) for Prior Auth CRD, DTR, and PAS APIs

Documentation

Write documentation from CMS rules

Write documentation from IGs

Derive Business Rules/Technical Specs from IGs for Architects/Developers and publish in Excel

Conduct presentations for all APIs to Architects/Developers

Mapping

Extensive knowledge of all FHIR resources, datatypes, codesets as used in the Da Vinci IGs and profiles

Ability to accurately map FHIR resources to canonical Elevance databases

SQL knowledge is very helpful

FHIR Synthesis

Produce valid FHIR payloads for all 3 APIs

Produce errant FHIR payloads for all 3 APIs

Validation

Good knowledge of FHIR Validators (validator.fhir.org, Inferno, various in-house validators)

Understand the use of Profiles and Versions in FHIR Validators

Ability to correct FHIR fatals/errors/warnings/informations found during validation

Produce error reports from testing of in-house FHIR validators

Testing

Design comprehensive test plans for all APIs

Produce FHIR payloads for all phases of test plans

Assist the Testing Team

Flexibility

This role requires a “Utility Player” who can help in many roles.

Be prepared for ad hoc assignments with quick turnaround requirements. Some are simple 1 hour tasks, some are complex week-long projects.

Prepare for working with a very large group of talented colleagues on-shore and off-shore.

Be ready for hard and fast deadlines for both CMS rules.

FHIR Knowledge

Profiles Used:

Da Vinci CRD

Da Vinci DTR

Da Vinci PAS

US Core (USCDI)

HRex

FHIR resources used daily

Coverage

Appointment

ServiceRequest

DeviceRequest

CommunicationRequest

Bundle

Encounter

Patient

Practitioner

PractitionerRole

Organization

Location

Questionnaire

QuestionnaireResponse

Critical FHIR extension: PriorAuth specific Coverage-Information extension

FHIR Knowledge (in rough order of complexity)

Understand how to use FHIR documentation

Cardinality (e.g., 0..* or 1..1)

MustSupport vs Required

Flags

References

Complex vs. Simple datatypes

ValueSets vs CodeSets

Verbiage for Constraints (SHALL | SHALL NOT | SHOULD | SHOULD NOT | MAY)

Structure Definitions (i.e., Differentials, Key Elements, Snapshot, Statistics, and All)

Bundles

CodeableConcepts vs Codes

Choice type element or dataType[x]

Modifiers

Extensions

Constraints

Contained Resources

Binding Strength

Profiles

Slices

Backbone Elements

Standard Statuses (i.e., TU, N, & D)

SDC Knowledge

Understand SDC Hooks, Cards, and System Actions

Prefetch