Manager, EDI

Fallon Health•Worcester, MA

2d•$130,000 - $135,000

About The Position

Fallon Health is hiring a Manager, EDI to manage, plan, and direct the daily operations of its EDI Department. The role ensures accurate, timely, and efficient EDI functions across the organization and communicates the business and operational impacts of technical tasks and issues to stakeholders. The manager oversees the end-to-end EDI lifecycle, including tracking incoming and outgoing files, investigating failed transmissions, identifying recurring issues, coordinating resolutions, and escalating provider and vendor concerns about submission discrepancies. The role also leads efforts to increase electronic submissions among contracted providers and clearinghouses. The manager trains, develops, and manages EDI staff; maintains EDI policies, procedures, and workflows; and collaborates with internal and external customers to meet service-level expectations and operational deadlines. Responsibilities include oversight of EDI systems and testing, regulatory compliance, audits, vendor relationships, staff performance, and continuous improvement. The position supports Fallon Health’s government-sponsored health insurance programs, including Medicare, Medicaid, and PACE.

Requirements

Bachelor’s degree required.
At least 7 years of experience in the operational environment of a Managed Care Organization (MCO).
Extensive experience with HIPAA-compliant transactions and applicable platforms such as Edifecs and BizTalk.
Extensive EDI experience, including regression testing, SNIP-level validation, transaction testing, and production issue resolution.
Hands-on operational experience with QNXT.
Basic SQL skills for troubleshooting, data validation, and issue analysis.
Strong knowledge of EDI production environments and workflows.
Proficiency with Microsoft Office, including Excel, Word, and PowerPoint, internet-based tools, and enterprise systems.
Ability to track, analyze, and resolve EDI production system issues across technical and business teams.
Ability to manage multiple demands and competing priorities in a fast-paced environment and evaluate short- and long-term impacts when making decisions.
Ability to use quantitative data to draw conclusions, identify trends, and support decision-making.
Strong verbal and written communication skills, including writing operational reports and correspondence and delivering clear presentations and impact analyses to leadership and technical audiences.
Ability to document policies and procedures clearly and in a structured format for diverse audiences.
Ability to learn and adapt quickly to new technologies and tools.
Adaptable and flexible in response to changing priorities.

Nice To Haves

Master’s degree or foreign equivalent in Electrical/Electronic Engineering, Electrical Power Systems, Computer Science, Engineering, or a related field.
Experience with HIPAA X12 transactions such as 270/271, 834, 837, and 835.
Experience managing vendor relationships and service-level agreements.
Familiarity with change management and release coordination.
Experience supporting CMS, Medicaid, Medicare, or MassHealth programs.
Experience with audit support, compliance, or regulatory reporting.
On-call or after-hours support experience.

Responsibilities

Manage, oversee, and monitor EDI team operations and functions, including EDI service-level agreements and key performance indicators.
Oversee the end-to-end EDI process, tracking incoming and outgoing files, claim counts, fatal edits, and processed files.
Monitor and research unsuccessful transmissions, identify trends, and coordinate resolutions with internal departments and external partners.
Oversee EDI claims reconciliation to ensure accuracy and completeness.
Monitor trading partners in testing phases and provide weekly status updates.
Manage communications and troubleshooting related to EDI submission issues with internal teams and contracted providers.
Lead continuous quality improvement initiatives across EDI processes.
Support internal and external audits related to EDI or claims and participate in enterprise change and release management.
Provide after-hours escalation or on-call support.
Test and sign off on Edifecs and QNXT system upgrades or changes related to electronic submissions.
Validate new and updated technology applications against existing EDI logic and communicate impacts and results to appropriate departments.
Oversee implementation and maintenance of HIPAA transaction sets, including 270/271, 276/277, 278, 820, 835, 837I, and 837P.
Ensure security setup and access controls for online tools, including Provider and Employer Tools.
Monitor, implement, and ensure compliance with state and federal regulations, HIPAA Privacy and Security standards, and CAQH CORE requirements.
Ensure EDI operations support regulatory, audit, and compliance expectations.
Assign, prioritize, and monitor staff work to ensure timely and accurate completion.
Train staff, set expectations, provide performance feedback, conduct annual reviews, and take corrective or remedial action when needed.
Review and approve time and attendance records and respond to staff and HR-related matters as needed.
Foster a cooperative team environment by communicating initiatives, resolving staff issues, encouraging feedback, and improving procedures.
Train EDI staff and provide training support to other departments as needed.
Maintain EDI policies, procedures, and workflows.
Act as liaison between EDI, IT, Configuration, and other internal departments to resolve operational issues.
Represent the EDI team in meetings with internal and external customers, including clearinghouse vendors.
Administer and manage relationships with EDI clearinghouse vendors.
Facilitate departmental meetings and deliver presentations to senior leadership as required.
Lead initiatives to increase provider electronic claims submissions and support organizational EDI adoption measures.
Drive improvements to EDI auto-adjudication rates in line with departmental strategic objectives.