Manager, EDI

Fallon Health•Worcester, MA

About The Position

Fallon Health is seeking a Manager, EDI, to manage, plan, and direct the daily operations of its EDI Department. The role ensures accurate, timely, and efficient execution of EDI functions and communicates the business and operational impacts of technical tasks and issues to stakeholders. The manager oversees the end-to-end EDI lifecycle, including incoming and outgoing files, failed transmissions, issue trends, reconciliation, and coordination with internal teams and external trading partners. The position also leads efforts to increase electronic submissions among contracted providers and clearinghouses. The manager is responsible for EDI staff training, development, and performance management, as well as documentation and maintenance of EDI policies and procedures. The role works with internal and external customers to meet service-level expectations and operational commitments, and to meet deadlines. It also oversees EDI-related systems testing, regulatory compliance, vendor relationships, and continuous improvement initiatives.

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.
Experience with HIPAA X12 transactions, such as 270/271, 834, 837, and 835.
Experience managing vendor relationships and service-level agreements.
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, work independently, and drive problems to closure.
Ability to evaluate short- and long-term impacts when making decisions and use quantitative data to draw conclusions, identify trends, and support decisions.
Exceptional 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.
Adaptability and flexibility 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, plus two years of experience as a Software Engineer or in a related occupation.
Experience supporting CMS, Medicaid, Medicare, or MassHealth programs.
Experience supporting audits, compliance, or regulatory reporting.

Responsibilities

Manage, oversee, and monitor all EDI team operations and functions.
Own EDI service-level agreements and key performance indicators, including throughput, error rates, and turnaround time.
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.
Oversee end-to-end EDI processing, including incoming and outgoing files, claim counts, fatal edits, and processed files.
Monitor and investigate unsuccessful transmissions, identify trends, and coordinate resolution with internal departments and external partners.
Oversee EDI claims reconciliation to ensure accuracy and completeness.
Oversee trading partners in testing phases, including providing weekly status updates.
Manage communications and troubleshooting for EDI submission issues with internal teams and contracted providers.
Lead continuous quality improvement initiatives across EDI processes.
Test and sign off on Edifecs and QNXT 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 meet regulatory, audit, and compliance expectations.
Assign, prioritize, and monitor staff work to ensure timely and accurate completion.
Train staff on job and organizational expectations; provide corrective or remedial action when necessary.
Provide ongoing performance feedback and conduct annual performance reviews.
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 constructive feedback, and adjusting procedures to improve efficiency.
Train EDI staff and provide training support to other departments as needed.
Maintain documentation of EDI team policies, procedures, and workflows.
Liaise 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 performance measures.
Drive improvements to EDI auto-adjudication rates in line with annual departmental strategic targets.