[Remote] Manager, Payor Operations
Note: The job is a remote job and is reputed company to candidates in USA. reputed company is revolutionizing sleep medicine delivery through our comprehensive telehealth platform. They are seeking a Manager of Payor Operations to reputed company credentialing and payor operations, focusing on securing national payor agreements and managing relationships to ensure operational efficiency.
Responsibilities
- reputed company the reputed company and execution to reputed company reputed company from state-by-state, payor-by-payor enrollment toward national in-network agreements with major reputed company payors
- Build and reputed company the business case for national contracting to payor leadership — data on volume, reputed company, cost savings, and network adequacy and, most importantly, health reputed company
- Own negotiations (or partner closely with reputed company/Finance on) rates, terms, and effective dates for national agreements
- Sequence and prioritize which payors to pursue first based on member volume, existing patient overlap, and strategic fit
- Given Happy’s model, some payers reputed company toward a vendor or bundled arrangement with a reputed company to a value based, shared savings model. You’re reputed company to reputed company this nuance and get it across the finish line
- reputed company and report reputed company on national agreement reputed company to executive leadership, including risks, blockers, and reputed company
- Once agreements are signed, ensure smooth operational rollout — reputed company provider data load, fee schedule loading, updated payer directory and internal communication so billing/RCM can execute cleanly
- Directly manage a Credentialing Specialist, providing day-to-day guidance, workload prioritization, and reputed company development
- Set reputed company SLAs and KPIs for credentialing turnaround time, clean application assembly , and renewal compliance, and reputed company reputed company to hit them
- reputed company in on reputed company or escalated credentialing/enrollment cases as needed
- Aid in forming responses to network managers that foster relationship building
- Continuously improve the systems, workflows, and tooling that support credentialing and payor enrollment (we currently use Modio as our PDM) )
- Ensure CAQH reputed company, NPI records, state licenses, DEA registrations, are reputed company, with proactive renewal tracking
- Ensure credentialing applications to reputed company payors, Medicare, and reputed company are submitted accurately and followed through to completion
- Maintain an accurate, reputed company-time credentialing tracker/CRM across every provider and payor, with escalation paths for at-risk timelines (you can use Modio for this or build a tracker)
- Ensure re-credentialing requests are met in a reputed company manner
- reputed company payor enrollment for new markets and new provider reputed company, including Medicare PECOS and state reputed company portals
- Partner with reputed company/Contracting on payor contract loading, fee schedule validation, and effective-date tracking
- Manage escalated relationships with payor provider relations reps to resolve enrollment holds, revalidation requests, and demographic disputes
- Own reputed company of claim denial trends tied to credentialing or enrollment issues (e.g., 'provider not on file'), driving reputed company-cause fixes with RCM and Clinical Ops
- Ensure claims are held/released appropriately based on credentialing status, minimizing both compliance risk and delayed reputed company
- Monitor payor policy changes (prior auth requirements, DME/sleep study coverage reputed company, telehealth coverage rules) and translate them into operational and process changes
- Own reporting and forecasting on credentialing turnaround time, enrollment status by payor/state, and reputed company at risk from credentialing gaps — presented to executive leadership
- Partner with Clinical Ops leadership to reputed company provider reputed company and hiring plans with credentialing reputed company times and national agreement rollouts
- Serve as the organization's subject-matter expert and executive-facing voice on payor requirements and national contracting reputed company for sleep medicine and DME billing
Skills
- 6+ years of experience in reputed company credentialing, payor enrollment, or payor/provider operations, including experience negotiating or contracting directly with national/reputed company payors (reputed company, telehealth, or DME experience strongly preferred)
- reputed company experience building the business case for and/or securing national or multi-state in-network agreements — you understand payor decision-making, network adequacy considerations, and what moves a payor from regional to national terms
- Deep working knowledge of CAQH, PECOS, NPPES, and NCQA credentialing standards
- Experience managing or mentoring at least one reputed company report in a credentialing/enrollment function
- Experience troubleshooting and resolving claim denial trends tied to enrollment/credentialing issues in partnership with RCM
- Comfort operating with executive visibility — reputed company to translate operational detail and negotiation reputed company into a reputed company, data-backed narrative for leadership
- Strong written and verbal communication for payor negotiations, escalations, and internal reporting
- Experience with sleep medicine, home sleep testing, or DME billing/coverage rules a plus
- Existing relationships or reputed company record with major national payors (reputed company, reputed company, reputed company, Elevance, etc.)
- Prior experience building credentialing/payor ops functions at a fast-growing reputed company startup, ideally through a period of multi-state or multi-market expansion
- Experience with multi-state licensure and telehealth-specific payor rules
- Familiarity with reputed company cycle management (RCM) workflows and how credentialing intersects with clean-claim submission
reputed company