EDI Coordinator

Overview

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—includding Medicare, Medicaid, and PACE—in the region. Learn more  or follow us on Facebook, Twitter and Linked In.

Brief summary of purpose:

The Electronic Data Interchange (EDI) Coordinator is an exempt position and a "key-player" on the operations team. The EDI Coordinator is responsible to facilitate the electronic flow of data from both internal and external customers. Our goal is to increase the volume of electronically submitted claims and our Auto-Adjudication of Claims. Includes oversight of EDI Process, working directly with our trading partners and government agencies to enhance the Secure and HIPAA Compliant, electronic flow of information.

The work involves tracking of incoming EDI files, monitoring, and researching unsuccessful transmissions, recognizing patterns, identifying issues, and building solutions to improve Fallon Health operations

Eligibility: This position requires permanent work authorization in the U.S. We will not provide visa sponsorship or accept candidates on OPT/CPT for this role.

Geographic eligibility: We can only hire from the following states for this position: MA, CT, RI, NH, NY (not Burroughs); FL, GA, TX, NJ; ME, VT.

• Assist in testing new and updated technology applications to the current EDI logic and then communicating the results to appropriate departments.
• Assist in the implementation of the HIPAA transaction sets across the company (270/271, 276/277, 278, 820, 834, 835, 837I and 837P).
• Leads the process of escalating the magnitude of providers who submit their claims to Fallon Health through electronic submission, including actively seeking new enrollees.
• Communicates with internal departments, as well as contracted providers, concerning submittal issues that require troubleshooting.
• Manages designated trading partner relationships.
• Tracks the incoming EDI file names, dates, claim counts, and fatal edits, including logged, run and process files to support timely and accurate reconciliation processes.
• Audits claims received via EDI to ensure accuracy.
• Seeks quality improvements for the EDI process.
• Supports timely, accurate setup and activation of portal accounts for providers and employers.

Education

• A Bachelor's Degree in Computer Information Systems is highly desired, but equivalent work experience will be considered.

Experience

Three (3) years experience in the operational side of a Health Insurance Organization. EDI/Edifecs and/or QNXT experience desired. Extremely PC savvy. Strong knowledge and experience with the MS Office Suite of products required, as well as Internet experience. Strong project leadership skills. Proven verbal and written communication skills.

• Adaptability
• Analytical Ability
• Perseverance
• Problem Solving
• Results Oriented
• Ability to document all policies and procedures in a format that is understandable by various readers

Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $85,000 annually 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.

Equal Employment Opportunity 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.