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Fallon Health EDI Coordinator in Worcester, Massachusetts


About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Position Summary:

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. This includes oversight of the EDIProcess, 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’s operations.


Primary Job Responsibilities:

  • Tracks the incoming EDI file names, dates, claim counts, and fatal edits, including logged, run and process files.

  • Support management of user accounts for employer and provider tools

  • Audits claims received via EDI to ensure accuracy.

  • Seeks quality improvements for the EDI process

  • Responsible for increasing the auto-adjudication rate of claims received through EDI.

  • Provides support to Sr EDI Coordinator role

  • Supports testing new and updated technology applications to the current EDI logic and then communicating the results to appropriate departments.

  • Supports the process of escalating the magnitude of providers who submit their claims to Fallon Community Health Plan (FCHP) through electronic submission, including actively seeking new enrollees.

  • Responsible for communicating with internal departments, as well as contracted providers, concerning submittal issues that require troubleshooting.


Education, Licenses, certification and experience requirements:

Education : A Bachelor’s Degree in Computer Information Systems Discipline or equivalent work experience.



Experience : Three (3) years’ experience in the operational side of a Health Insurance Organization. IDX 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.

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.

Location US-MA-Worcester

Posted Date 3 weeks ago (3/19/2020 1:12 PM)

Job ID 5955

# Positions 1

Category Information Technology