EDI Coordinator

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: 

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

Primary Job Responsibilities

• 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.
• Responsible for communicating with internal departments, as well as contracted providers, concerning submittal issues that require troubleshooting.
• Responsible for managing 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.
• Support timely, accurate setup and activation of portal accounts for providers and employers

Bachelor’s Degree required. 

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.  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.

Other abilities and requirements

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

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.