Director, Part C & Authorizations

Overview At Habitat Health, we envision a world where older adults experience an independent and joyful aging journey in the comfort of their homes, enabled by access to comprehensive health care. Habitat Health provides personalized, coordinated clinical and social care as well as health plan coverage through the Program of All-Inclusive Care for the Elderly (“PACE”) in collaboration with our leading healthcare partners, including Kaiser Permanente. Habitat Health offers a fully integrated experience that brings more good days and a sense of belonging to participants and their caregivers. We build engaged, fulfilled care teams to deliver personalized care in our centers and in the home. And we support our partners with scalable solutions to meet the health care needs and costs of aging populations. Habitat Health is growing, and we’re looking for new team members who wish to join our mission of redefining aging in place. To learn more, visit the Habitat Health website. Role Scope Role scope : Our Health Plan is looking for a detail oriented, process driven individual to join our team with deep knowledge of claims processing and utilization management to provide strategic leadership and operational oversight to shape a vital subfunction at our organization. This role will build scalable processes to ensure the accuracy, timeliness, and quality of service authorizations, claims adjudication, and encounter data by conducting retrospective reviews, maintaining robust reporting, and overseeing daily operational performance. It collaborates across functions to resolve data discrepancies, monitor inventory and production stability, and provide leadership with actionable insights that drive continuous process improvement. Responsibilities 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. Qualifications 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). Equity, Inclusion, and Employment Policy Habitat Health is an Equal Opportunity employer and is committed to creating a diverse and inclusive workplace. Applicants are considered based on qualifications without regard to race, color, religion, creed, sex, gender identity or expression, sexual orientation, national origin, age, disability, or other status protected by law. Reasonable accommodations may be provided during the application process and employment, as required by law. #J-18808-Ljbffr Habitat Health