Director of EDI

Job Description

The Director of Electronic Data Interchange (EDI) oversees and manages all EDI transactions between Pinnacle TPA, its clients, and vendors. Key responsibilities include:

• Oversee and manage the configuration, testing, and execution of all EDI transactions.
• Maintain a high level of data integrity and compliance with industry standards.
• Develop and maintain complex SQL queries and scripts used to create data marts in Teradata.
• Design, develop, implement, and maintain Business Intelligence reports using healthcare claims data.
• Develop complex business intelligence solutions and supporting data strategies.
• Develop complex dashboards, scorecards, reports, and data analysis using X12/EDI pre-adjudicated data.
• Lead integration and system testing.
• Act as the primary liaison for all EDI interactions with clients and vendors.
• Ensure that all EDI setups, processes, and configurations are tailored to client and vendor requirements while adhering to internal standards.
• Facilitate the resolution of any EDI transaction errors or issues promptly.
• Manage the EDI interface platform, ensuring it is correctly configured for all transaction sets and data exchanges.
• Oversee the ongoing maintenance and monitoring of the platform, working with the IT team to ensure any updates or changes are implemented effectively.
• Develop and maintain comprehensive documentation for all EDI processes, transactions, and configurations.
• Establish and maintain detailed operational workflows and procedures.
• Proactively monitor all EDI transactions to identify and resolve errors or discrepancies.
• Conduct root cause analysis for recurring issues and implement preventative solutions.
• Identify opportunities to improve and streamline EDI processes within the department.
• Recommend and implement process enhancements to increase the efficiency and accuracy of data exchanges.
• Stay current with industry trends and updates to the ANSI X12 standard and recommend necessary changes to the existing processes or systems.
• Work closely with IT, claims, operations, and other departments to align EDI processes with the company’s operational goals.
• Ensure that all cross-functional teams are informed and trained on any updates or changes to the EDI processes.

Qualifications

• Bachelor's or Master's degree in Information Technology, Computer Science, or a related field.
• Eight to ten years of experience managing EDI operations within a healthcare setting, specifically focusing on eligibility, premium billing, invoicing, and the ANSI X12 EDI standard.
• Hands-on experience with EDI interface platforms such as Pilotfish or similar integration tools.
• Strong knowledge of healthcare-related EDI transaction sets (837, 834, 835, 270, 271, etc.).
• Comprehensive expertise in data mapping, EDI standards, and transaction troubleshooting.
• Strong understanding of HIPAA regulations and how they apply to EDI data exchanges.
• Advanced knowledge of healthcare processes, including eligibility verification, claims processing, and payment transactions.
• Prioritization of process documentation, creation of operational workflows, and improving departmental efficiency.
• Strong leadership and project management skills, with the ability to manage cross-functional teams and external vendor relationships.
• Excellent verbal and written communication skills, with the ability to explain complex technical details to non-technical stakeholders.
• Strong skills in troubleshooting, root cause analysis, and implementing effective solutions to EDI-related challenges.

Compensation

$102,058.25 - $145,033.48 with a rich benefits package that includes profit-sharing. This is a remote position.