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 at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

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.

Responsibilities Job Responsibilities:

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.

Qualifications 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:

If education major is in other than preferred, then 4-7 years' experience in the operational side of a Managed Care Organization or 2+ years of experience with preferred degree. 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. EDI experience required including regression testing, SNIP level validation and basic SQL skills required for troubleshooting and validating issues. 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. #P01