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Fallon Health Senior 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.

Brief Summary of Purpose: Oversees the EDI Process for the company, including tracking of all incoming and outgoing EDI files, monitoring and researching unsuccessful transmissions, recognizing patterns and contacting appropriate parties for resolution of issues, handling provider concerns over submittal discrepancies and taking the lead on increasing the volume of contracted providers using electronic submission. Responsible for training and development of all EDI staff and documenting all new procedures. Works with internal and external customers to fulfill tasks and meet deadlines. Candidate should function under minimal supervision, typically working independently


  • Acts as the liaison between internal departments including IT and Configuration and the EDI Coordinators to handle day to day questions and issue resolution

  • Responsible for training all staff on the EDI team, as well as training other department members as needed

  • Responsible for the implementation of the HIPAA transaction sets across the company (270/271, 276/277, 278, 820, 835, 837I and 837P)

  • Responsible for representing the EDI Team in all meetings with internal and external customers

  • Responsible for security set up for all online tools, including the Provider Tools and Employer Tools

  • Responsible for documentation of all policies and procedures for the EDI team

  • Responsible for running the KEA scripting software for the Weight Watchers claims

  • Responsible for providing weekly updates on all Trading Partners in the testing phases

  • Responsible for all testing of Edifecs and QNXT system upgrades or changes as they relate to electronic submission

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

  • Leads the process of escalating the magnitude of providers who submit their claims to Fallon Health through electronic submission, including actively seeking new enrollees to maximize the performance measures for Fallon’s EDI rate.

  • Responsible for increasing the auto-adjudication rate of claims received through EDI. Targets defined annually through departmental major strategic objectives.

  • Manages all communications with internal departments, as well as contracted providers, concerning submittal issues that require troubleshooting.

  • Responsible for administrating the Health Plan’s relationship with Clearinghouse vendors.

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

  • Seeks quality improvements for the EDI process.

  • Oversight and monitoring of claims reconciliation process for EDI claim submissions.


Education, Licenses, certification and experience requirements:

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 : 5-7 years experience in the operational side of a Managed Care Organization. QNXT experience a must. Extremely PC savvy. Strong knowledge of MS Office required, Internet experience, as well as Biztalk. Strong project leadership skills. Proven verbal and written communication skills.

Other abilities and requirements

  • Adaptable

  • Results-oriented

  • Command skills

  • Handles multiple demands and competing priorities.

  • Evaluates short- and long-term consequences when making decisions.

  • Uses quantitative data to draw conclusions.

  • Grasps complexities and perceives relationships among problems or issues. Demonstrates a sense of urgency and drives issues to closure.

  • Superlative verbal communication and presentation skills.

  • Demonstrated ability to quickly learn new technology.

  • Ability to work independently.

  • Able to coordinate and lead meetings with internal staff and outside vendors, following issues raised until they are brought to resolution.

  • Ability to train all new staff, or current staff on new procedures

  • Ability to document all policies and procedures in a format that is understandable by various readers

Location US-MA-Worcester

Posted Date 1 month ago (9/11/2020 2:44 PM)

Job ID 6066

# Positions 1

Category Information Technology