QA(FHIR)-Remote

Role: QA (FHIR)

Location: 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