Manager, Payor Operations

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Happy Health

Site WebLinkedInTous les Emplois

11 - 50 employés

🏥 Santé

🔧 Matériel

🤖 Intelligence artificielle

💰 €60 000 000 Series A - Happy Health en 2022-08

Healthcare • Hardware • Artificial Intelligence

Happy Health est une entreprise de médecine du sommeil axée sur le consommateur qui exploite la plateforme Happy Sleep. Elle combine un dispositif médical portable approuvé par la FDA (le Happy Ring) pour des tests de sommeil de qualité clinique à domicile avec des soins virtuels fournis par des médecins du sommeil certifiés par le conseil d'administration et une équipe de soins coordonnée. La société propose des tests de sommeil à domicile sur ordonnance, des options de traitement personnalisées (CPAP, dispositifs sur mesure, chirurgie, interventions comportementales), une surveillance nocturne et un suivi continu, un suivi de santé amélioré par l'IA, des rendez-vous virtuels le jour même, et travaille avec les principaux assureurs dans la plupart des États américains.

Description

• Lead the strategy and execution to move Happy Sleep from state-by-state, payor-by-payor enrollment toward national in-network agreements with major commercial payors • Build and pitch the business case for national contracting to payor leadership — data on volume, quality, cost savings, and network adequacy and, most importantly, health outcomes • Own negotiations (or partner closely with Legal/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 • Track and report progress on national agreement pursuit to executive leadership, including risks, blockers, and timeline • Ensure smooth operational rollout — timely 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 professional development • Set clear SLAs and KPIs for credentialing turnaround time, clean application assembly, and renewal compliance, and coach the team to hit them • Continuously improve the systems, workflows, and tooling that support credentialing and payor enrollment • Ensure CAQH profiles, NPI records, state licenses, DEA registrations, are current, with proactive renewal tracking • Oversee payor enrollment for new markets and new provider onboarding, including Medicare PECOS and state Medicaid portals • Manage escalated relationships with payor provider relations reps to resolve enrollment holds, revalidation requests, and demographic disputes • Own resolution of claim denial trends tied to credentialing or enrollment issues driving root-cause fixes with RCM and Clinical Ops • Own reporting and forecasting on credentialing turnaround time, enrollment status by payor/state, and revenue at risk from credentialing gaps — presented to executive leadership

🎯 Exigences

• 6+ years of experience in healthcare credentialing, payor enrollment, or payor/provider operations, including experience negotiating or contracting directly with national/commercial payors (healthcare, telehealth, or DME experience strongly preferred) • Direct 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 direct 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 — able to translate operational detail and negotiation strategy into a clear, 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

🏖️ Avantages

• 100% premium coverage for employee's Health, Dental, and Vision Insurance. 50% premium coverage for dependents. • 401k platform • Equity in company • WFH Stipend