Manager, Payor Operations

This is a fully remote position, open to applicants in United States.

📋 Description

• Spearhead the strategy and implementation to transition Happy Sleep from state-by-state, payor-by-payor enrollment to national in-network agreements with leading commercial payors.

• Develop and present the business case for national contracting to payor leadership, focusing on data related to volume, quality, cost savings, network adequacy, and crucially, health outcomes.

• Take ownership of negotiations (or collaborate closely with Legal/Finance) concerning rates, terms, and effective dates for national agreements.

• Sequence and prioritize which payors to target initially based on member volume, existing patient overlap, and strategic alignment.

• Monitor and report on the progress of national agreement pursuits to executive leadership, highlighting risks, obstacles, and timelines.

• Ensure a seamless operational rollout, including timely provider data loading, fee schedule updates, payer directory revisions, and internal communications for effective billing/RCM execution.

• Directly supervise a Credentialing Specialist, offering daily guidance, workload prioritization, and support for professional growth.

• Establish clear SLAs and KPIs for credentialing turnaround times, clean application assembly, and renewal compliance, coaching the team to meet these standards.

• Continuously enhance the systems, workflows, and tools that facilitate credentialing and payor enrollment.

• Maintain current CAQH profiles, NPI records, state licenses, and DEA registrations, with proactive renewal tracking in place.

• Oversee payor enrollment for new markets and onboarding of new providers, including Medicare PECOS and state Medicaid portals.

• Manage advanced relationships with payor provider relations representatives to address enrollment holds, revalidation requests, and demographic discrepancies.

• Take charge of resolving claim denial trends linked to credentialing or enrollment issues, driving root-cause solutions with RCM and Clinical Operations.

• Own the reporting and forecasting on credentialing turnaround times, enrollment statuses by payor/state, and revenue at risk due to credentialing gaps, presenting findings to executive leadership.

⛳️ Requirements

• 6+ years of experience in healthcare credentialing, payor enrollment, or payor/provider operations, with a strong preference for experience in negotiating or contracting directly with national/commercial payors (healthcare, telehealth, or DME experience is highly desirable).

• Proven experience in creating the business case for and/or securing national or multi-state in-network agreements—demonstrating an understanding of payor decision-making, network adequacy considerations, and factors that influence a payor's shift from regional to national terms.

• Extensive working knowledge of CAQH, PECOS, NPPES, and NCQA credentialing standards.

• Experience managing or mentoring at least one direct report in a credentialing/enrollment role.

• Experience in troubleshooting and resolving claim denial trends associated with enrollment/credentialing issues in collaboration with RCM.

• Comfortable operating under executive visibility—able to translate operational details and negotiation strategies into a clear, data-driven narrative for leadership.

• Strong written and verbal communication skills for payor negotiations, escalations, and internal reporting.

• Experience in sleep medicine, home sleep testing, or DME billing/coverage rules is an advantage.

🏝️ Benefits

• 100% premium coverage for employee's Health, Dental, and Vision Insurance, with 50% premium coverage for dependents.

• 401k platform.

• Equity in the company.

• WFH Stipend.