Manager, EDI - WFH

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—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)—in the region.

Learn more  or follow us on Facebook, Twitter and Linked In.

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 and 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 Responsibilites

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…