EDI Operations Manager — Healthcare & Compliance

Fallon Community Health Plan, Inc.; Worcester (MA); On-site; USD 130,000 - 135,000; Full time

Benefits offered by this job

Competitive salary

Job summary

Fallon Health in Worcester, MA is seeking a senior EDI Operations Leader to manage end-to-end EDI workflows, SLAs, and cross‑functional collaboration. You will supervise staff, coordinate with providers and clearinghouses, and drive quality improvements in HIPAA transaction processing.

Responsibilities include overseeing testing of Edifecs/QNXT changes, maintaining security controls, and ensuring regulatory compliance while guiding a high‑performing team.

Qualifications

• Bachelor’s degree required; master’s degree preferred in a related field.
• 7+ years in the operational environment of a Managed Care Organization (MCO).
• Extensive experience with HIPAA transactions and platforms (Edifecs, BizTalk, QNXT).
• Strong SQL skills for troubleshooting and data validation.
• Experience managing vendor relationships and SLAs; CMS/Medicare/MassHealth exposure is a plus.
• Proven ability to drive PDCA/quality initiatives and regulatory compliance.

Responsibilities

• Oversee and monitor all EDI team operations and functions.
• Own EDI SLAs and KPIs, ensure timely and accurate processing.
• Support audits and participate in enterprise change/release management.
• Lead and manage after-hours escalation and on-call coverage.
• Track EDI lifecycle, monitor transmissions, and coordinate issue resolution.
• Oversee EDI claims reconciliation and vendor relationships.
• Ensure security controls and HIPAA compliance across tools and systems.
• Lead training and documentation of EDI policies and procedures.
• Communicate with internal/external stakeholders and senior leadership.

Skills

MCO operations experience

EDI transactions & HIPAA

Vendor management & SLAs

SQL basics

Communication & reporting

Education

Bachelor’s Degree

Master’s or foreign equivalent in related field

Tools

Edifecs

QNXT

BizTalk

Job description

Fallon Health in Worcester, MA is seeking a senior EDI Operations Leader to manage end-to-end EDI workflows, SLAs, and cross‑functional collaboration. You will supervise staff, coordinate with providers and clearinghouses, and drive quality improvements in HIPAA transaction processing.

Responsibilities include overseeing testing of Edifecs/QNXT changes, maintaining security controls, and ensuring regulatory compliance while guiding a high‑performing team.