Director, Part C & Authorizations
Habitat Health
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $153,000 - $170,000 per year
Job Level
About the role
- Sets the vision, operating standards, and governance framework for Part C authorizations, claims processing (including TPA oversight), and encounter data operations, ensuring regulatory compliance and operational consistency.
- Oversees day-to-day adjudication operations, ensuring a controlled, disciplined, regulatorily compliant and exceptionally reliable operational environment that is timely, accurate, and has a high-quality output by internal team members and external vendors, as necessary.
- Responsible for establishing and maintaining and evolving reports and performance management frameworks, including KPIs, audit outcomes, utilization metrics, and risk indicators, and communicate insights to senior leadership.
- Owns end-to-end encounter data processing including reviewing and monitoring encounter data submissions for accuracy, ensuring discrepancies are identified, corrected, and communicated through collaboration with crossfunctional teams; maintaining documentation and troubleshooting processes to support data quality.
- Engages with Enrollment & Eligibility to resolve data discrepancies impacting member benefits or provider assignments. Partners with Provider Network on contract load timing, unclear terms, and pricing interpretation issues.
- Conducts retrospective reviews and maintains reporting that evaluates the accuracy, timeliness, and effectiveness of service authorization processes, providing clear summaries of findings and outcomes to leadership to drive continuous improvement.
- Monitors daily, weekly, and monthly inventory at the claim, and authorization and encounter data level to anticipate risk and maintain a stable production environment.
Requirements
- 8+ years of experience in health insurance operations, including team leadership and direct supervisory experience
- Demonstrated expertise in claims processing and utilization management
- Background in capitated health plan financials; PACE experience strongly preferred.
- Strong customer service orientation and ability to handle confidential information.
- Excellent verbal and written communication skills.
- Bachelor’s degree in healthcare, finance, or related field required; Master’s degree preferred.
- Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).
Benefits
- Health insurance
- Life insurance
- Participation in the company’s equity program
- Paid time off, including vacation and sick leave
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims processingutilization managementdata qualityperformance managementKPI developmentaudit outcomesrisk indicatorsencounter data processingreportingdata discrepancies resolution
Soft Skills
team leadershipsupervisory experiencecustomer service orientationconfidential information handlingverbal communicationwritten communicationcollaborationcontinuous improvementproblem-solvinganalytical thinking