Director, EDI

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Director, EDI (Electronic Data Interchange) reporting to the Chief Information & System Modernization Officer, is responsible for leading the strategic planning, implementation, and maintenance of EDI systems to ensure seamless electronic data transactions between healthcare providers, payers, and other stakeholders in the health insurance ecosystem. This role focuses on optimizing data exchange efficiency, maintaining compliance with industry regulations (e.g., HIPAA), and driving innovation in EDI operations to support the organization’s goals.

Amount of Travel Required: 5-10%

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities

•    Develop and execute an EDI strategy aligned with the organization’s overall objectives.

•    Lead cross-functional teams to implement EDI solutions that enhance operational efficiency and data accuracy.

•    Stay updated on industry trends, standards, and emerging technologies in EDI and health insurance.

•    Oversee the design, testing, implementation, and maintenance of EDI systems.

•    Monitor the performance and reliability of EDI processes to ensure timely and accurate data exchange.

•    Manage relationships with trading partners, vendors, and clearinghouses.

•    Ensure compliance with healthcare industry regulations, including HIPAA, ACA, and other state and federal mandates.

•    Conduct regular audits and implement controls to mitigate data security and integrity risks.

•    Build and lead a high-performing EDI team by recruiting, training, and mentoring staff.

•    Establish performance metrics and drive accountability within the team.

•    Identify opportunities to enhance EDI processes through automation and technology upgrades.

•    Collaborate with IT, operations, and business teams to streamline workflows and improve data integration.

MINIMUM QUALIFICATIONS

Education & Experience:

•    Bachelor’s degree in Computer Science, Information Systems, or related field.

•    Requires 8+ years of EDI operations experience in a health plan, with at least 3-5 years in a leadership role.

•    Eight years of health plan experience in lieu of a bachelor’s degree.

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:    

•    Deep understanding of healthcare data standards (e.g., ANSI X12, HL7, FHIR) and transaction sets (e.g., 837, 835, 270/271).

•    Strong knowledge of HIPAA compliance requirements and healthcare interoperability frameworks.

•    Proven experience managing vendor relationships and third-party integrations.

•    Exceptional leadership, project management, and problem-solving skills.

•    Proficiency in EDI mapping tool