About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose: 

Manage, plan, and direct the daily operations of the EDI Department to ensure accurate, timely, and efficient execution of all EDI functions across Fallon Health. Accountable for ensuring the EDI team operates at peak effectiveness, delivering consistently high standards of accuracy, timeliness, and reliability in support of organizational goals. Plays a critical role in communicating the business and operational impacts of technical tasks and issues, ensuring downstream effects are clearly understood by all stakeholders**.

Oversee the end‑to‑end EDI lifecycle for the organization, including tracking all incoming and outgoing EDI files, monitoring and researching failed or unsuccessful transmissions, identifying trends or recurring issues, and coordinating resolution with internal teams and external trading partners. Serve as a point of escalation for provider & vendor concerns related to submission discrepancies and lead initiatives to increase the adoption of electronic submissions among contracted providers and clearinghouses**.

Responsible for the training, development, and performance management of EDI staff, as well as the documentation and maintenance of all EDI‑related policies and procedures. Collaborate closely with internal and external customers to meet service-level expectations, fulfill operational commitments, and ensure deadlines are consistently met.

Primary Job Responsibiliites

Operational & EDI Oversight

• Manage, oversee, and monitor all EDI team operations and functions.
• Ownership of EDI SLAs and KPIs (throughput, error rates, turnaround time)**
• Support for audits (internal/external) related to EDI or claims **
• Participation in enterprise change management / release management **
• After‑hours escalation or on‑call responsibilities **
• Oversee the end‑to‑end EDI process, including tracking all incoming and outgoing files, claim counts, fatal edits, and processed files.
• Monitor and research unsuccessful transmissions; identify trends and coordinate issue resolution with internal departments and external partners.
• Provide oversight of EDI claims reconciliation processes to ensure accuracy and completeness.
• Oversee monitoring of Trading Partners in testing phases, including weekly status updates.
• Manage all communications related to EDI submission issues requiring troubleshooting with internal teams and contracted providers.
• Lead continuous quality improvement initiatives across EDI processes.

Systems, Testing & Technology

• Responsible for testing and signoff of all Edifecs and QNXT system upgrades or changes related to electronic submissions.
• Accountable for validating new and updated technology applications against existing EDI logic and communicating impacts and results to appropriate departments.
• Oversee implementation and maintenance of HIPAA transaction sets (270/271, 276/277, 278, 820, 835, 837I, 837P).
• Ensure security setup and access controls for online tools, including Provider and Employer Tools.

 Compliance & Regulatory

• Monitor, implement, and ensure compliance with State and Federal regulations, including HIPAA Privacy and Security standards and CAQH CORE requirements.
• Ensure EDI operations support regulatory, audit, and compliance expectations.
• Staff Management & Development

 Assign, prioritize, and monitor work to ensure timely and accurate completion.

• Ensure staff are properly trained, understand job and organizational expectations, and receive corrective or remedial action when necessary.
• Provide ongoing performance feedback and conduct annual performance reviews.
• Review and approve time and attendance records in accordance with company standards.
• Respond to staff and HR‑related matters as needed.
• Foster a cooperative team environment by:

 Communicating department and company initiatives

• Resolving staff issues
• Encouraging constructive feedback
• Adjusting procedures to improve efficiency

 Training & Documentation

• Responsible for training all EDI staff and providing training support to other departments as needed.
• Ensure documentation and maintenance of all EDI team policies, procedures, and workflows.

 Leadership, Communication & Representation

• Act as liaison between EDI, IT, Configuration, and other internal departments to resolve day‑to‑day 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.

Strategic & Performance Measures

• Lead initiatives to increase the volume of providers submitting claims electronically, supporting organizational performance measures for EDI adoption.
• Drive improvements to EDI auto‑adjudication rates, with annual targets defined through departmental strategic objectives.

Education

Bachelor’s Degree required. 

Master’s degree or foreign equivalent in Electrical/Electronic Engineering, Electrical Power Systems, Computer Science, Engineering, or a related field and two (2) years of experience as a Software Engineer or a related occupation preferred.

Experience

Required Experience & Technical Skills

• 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 required**.
• Extensive EDI experience, including:
  • Regression testing
  • SNIP level validation
  • Transaction testing and production issue resolution
• QNXT experience required (hands-on, operational).
• Basic SQL skills required for troubleshooting, data validation, and issue analysis.
• Strong knowledge of EDI production environments and workflows.**
• Technically savvy with strong proficiency in Microsoft Office (Excel, Word, PowerPoint), internet-based tools, and enterprise systems.**
• Experience with HIPAA X12 transactions (e.g., 270/271, 834, 837, 835)**
• Experience managing vendor relationships and SLAs**
• Familiarity with change management and release coordination**
• Experience supporting CMS, Medicaid, Medicare, or MassHealth programs**
• On-call or after-hours support expectations **
• Experience with audit support, compliance, or regulatory reporting**

 Operational & Analytical Skills

• Grasps complex systems and identifies relationships across issues, driving problems to closure with urgency.
• Strong results-oriented mindset with the ability to work independently.
• Ability to track, analyze, and resolve EDI production system issues, including working across technical and business teams.
• Handles multiple demands and competing priorities effectively in a fast-paced environment.
• Evaluates short- and long-term impacts when making decisions
• Uses quantitative data to draw conclusions, identify trends, and support decision-making

Communication & Documentation

• Exceptional verbal and written communication skills, including:
• Writing routine operational reports and correspondence
• Delivering clear presentations/impact analysis to leadership and technical audiences**
• Ability to document policies and procedures in a clear, structured format understandable to diverse audiences.
• Demonstrated ability to quickly learn and adapt to new technologies and tools.

 Professional Attributes

• Adaptable and flexible in response to changing priorities.

Pay Range Disclosure:

In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $130,000 - $135,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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