Habitat Health

Compensation

Full Description

Job Description: • 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