The Director of Electronic Data Interchange (EDI) is responsible for overseeing and managing all EDI transactions between Pinnacle TPA, its clients, and vendors. This role ensures the seamless, accurate, and timely exchange of data using the ANSI X12 EDI standard within the healthcare environment. The Director will manage the EDI interface platform, coordinate with internal teams and external partners, and ensure compliance with industry regulations such as HIPAA. Additionally, the Director will document all EDI-related processes, create operational workflows, and improve departmental efficiency. Serving as the primary contact for all EDI-related inquiries and issues, the Director will ensure that all transactions, configurations, and procedures align with Western Growers Family of Companies (WGFC) overall business objectives. This position reports directly to the Vice President of Information Technology (VP of IT) and requires cross-functional collaboration to align the company's EDI processes with its overall business strategy and compliance requirements.

Qualifications

• BA/BS degree in Information Technology, Computer Science, or a related field ), along with eight (8) to ten (10) years of experience managing EDI operations within a healthcare setting—specifically focusing on eligibility, premium billing, invoicing, and the ANSI X12 EDI standard, preferred.
• Hands-on experience with the 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, is essential.
• Proven ability to document processes, procedures, and workflows in a clear and detailed manner.
• Experience in process improvement and optimizing transaction workflows.
• 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.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.

Duties And Responsibilities

• Oversee and manage the configuration, testing, and execution of all EDI transactions, including 837 (claims), 834 (enrollment), 835 (remittance advice), and 270/271 (eligibility inquiries and responses), among others.
• Ensure smooth, accurate, and timely data exchanges with clients and vendors.
• 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.
•  Gather business requirements and prepare analyses based on information from internal and external sources to evaluate and demonstrate program effectiveness and efficiency supporting projects and change requests.
• Design, develop, implement, and maintain Business Intelligence reports using healthcare claims data.
• Develop complex business intelligence solution and supporting data strategy leveraging acquired subject matter expertise to identify opportunities and risks.
• Develop complex dashboards, scorecards, reports, and data analysis using X12/EDI pre-adjudicated data including 835, 277, and 837 transitions.
• Improve the delivery and management of programs by utilizing advanced analytics, including but not limited to advanced algorithms, data visualizations, and maps.
• 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.
• Ensure all EDI activities comply with HIPAA regulations and industry standards.
• Establish and maintain detailed operational workflows and procedures.
• Proactively monitor all EDI transactions to identify and resolve errors or discrepancies.
• Work with the IT and operations teams to investigate and correct any issues that arise during data exchanges.
• Ensure root cause analysis is conducted 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.

• Develop, manage, and lead a team of 3A+ self-accountable professionals.
• Develop a culture of real, personal accountability by modeling the behavior that defines it.
• Instill a culture of safety and expectation, within your respective area/s.
• Require direct reports to hold themselves accountable to high standards of, performance and personal conduct, in a clear, helpful, straightforward way.
• Conduct one-on-one conversations with every direct report, on a quarterly basis, focused on their 3A+ capabilities, impact, and effort.
• Make decisions and choices, impacting staff, by using the selection and hiring, clarifying roles and objectives, managing performance, correction & discipline and termination steps as outlined in the “Outward Mindset Skills for Leaders” guide.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit.
• All other duties as assigned.

Physical Demands/Work Environment