Director, Payor Operations

Role Overview

• Own and maintain a centralized payer rulebook across all health plans
• Interpret payer requirements and translate them into clear operational workflows
• Standardize workflows where possible while maintaining plan-specific requirements
• Continuously update workflows as requirements evolve
• Own performance outcomes at the health plan level (KPIs, compliance, documentation)
• Monitor performance across geographies and identify gaps
• Ensure consistency in workflow execution across teams
• Hold internal teams accountable for plan-level performance issues
• Diagnose root cause of issues (execution vs workflow vs capacity vs quality)
• Assign ownership and track resolution
• Lead corrective actions for underperforming plans
• Escalate systemic issues across plans
• Manage L4 Plan Owners responsible for plan-level oversight
• Define expectations for monitoring, escalation, and issue tracking
• Oversee Payor Ops Trainer responsible for content development and rollout support
• Ensure team operates with clarity and consistent ownership boundaries
• Ensure payer requirements are translated into training-ready materials
• Support rollout of workflow changes in partnership with CHW Workforce
• Ensure plan-specific nuances are accurately captured
• Validate that training content reflects current payer requirements

Requirements

• 7–10+ years of experience in healthcare operations, payer operations, compliance, or related functions
• Strong working knowledge of Medicaid managed care and payer-driven program requirements
• Demonstrated experience interpreting payer or regulatory requirements and translating them into operational workflows
• Experience managing multiple external stakeholders (health plans, partners) with differing requirements
• Experience leading or supporting audit, QA, or compliance processes
• Strong analytical skills with the ability to diagnose operational issues across execution, workflow, and capacity
• Experience managing complex, cross-functional work without direct authority over execution teams.

Benefits

• Equity compensation package
• Comprehensive benefits including medical, dental, and vision
• 401k
• Flexible PTO policy
• take the time you need to recharge
• $1,000 home office stipend
• We provide the equipment needed for this role.
• Opportunity for rapid career progression with plenty of room for personal growth.