Senior EDI Operations Manager

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

Job summary

Fallon Health in Worcester, MA, seeks a senior EDI Operations leader to manage the daily work of the EDI Department, ensuring accurate, timely electronic submissions and strong SLA adherence. You will drive end-to-end EDI lifecycle, monitor transmissions, and coordinate with providers, vendors, and internal teams.

The role requires 7+ years in a managed care setting and deep HIPAA transaction experience, with hands-on work using Edifecs, BizTalk, and QNXT.

Qualifications

• 7+ years in the operational environment of a Managed Care Organization (MCO).
• Extensive Experience with HIPAA compliant transactions and platforms such as Edifecs and BizTalk.
• Extensive EDI experience, including: Regression testing, SNIP level validation, transaction testing and production issue resolution.
• QNXT experience required (hands-on, operational).
• Basic SQL skills required for troubleshooting, data validation, and issue analysis.
• Strong knowledge of EDI production environments and workflows.
• Experience managing vendor relationships and SLAs.
• Experience supporting CMS, Medicaid, Medicare, or MassHealth programs.
• On-call or after-hours support expectations.
• Excellent communication and documentation skills.

Responsibilities

• Oversee operational EDI production and SLAs to ensure timely submissions.
• Lead testing and sign-off of Edifecs and QNXT upgrades or changes.
• Ensure HIPAA compliance and regulatory reporting related to EDI.
• Manage vendor relationships and SLAs with clearinghouses and providers.
• Provide training and documentation for EDI staff and cross-functional teams.
• Represent EDI in meetings with internal and external customers.

Skills

EDI operations

HIPAA transactions

Vendor management

SQL troubleshooting

QNXT knowledge

Change management

CMS/MassHealth experience

Education

Bachelor's Degree

Master's degree or foreign equivalent

Tools

Edifecs

BizTalk

QNXT

Job description

Fallon Health in Worcester, MA, seeks a senior EDI Operations leader to manage the daily work of the EDI Department, ensuring accurate, timely electronic submissions and strong SLA adherence. You will drive end-to-end EDI lifecycle, monitor transmissions, and coordinate with providers, vendors, and internal teams.

The role requires 7+ years in a managed care setting and deep HIPAA transaction experience, with hands-on work using Edifecs, BizTalk, and QNXT.