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Role Description

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.

• 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).

Requirements

• Vaccination Policy, including COVID-19: At Habitat Health, we aim to provide safe and high-quality care to our participants. To achieve this, please note that we have vaccination policies to keep both our team members and participants safe. For covid and flu, we require either proof of vaccination or declination form and required masking while in participant locations as a safe as an essential requirement of this role. Requests for reasonable accommodations due to an applicant’s disability or sincerely held religious beliefs will be considered and may be granted based upon review. We also require that team members adhere to all infection control, PPE standards and vaccination requirements related to specific roles and locations as a condition of employment.

Compensation

• We consider an individual’s qualifications, skillset, and experience in determining final salary.
• This role is eligible for health insurance, life insurance, participation in the company’s equity program, and paid time off, including vacation and sick leave.
• The expected salary range for this position is $153,000 to $170,000. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location.

Our Commitment to Diversity, Equity, and Inclusion

• Habitat Health is an Equal Opportunity employer and is committed to creating a diverse and inclusive workplace.
• Habitat Health applicants are considered solely based on their qualifications, without regard to race, color, religion, creed, sex, gender (including pregnancy, childbirth, breastfeeding or related medical conditions), gender identity, gender expression, sexual orientation, marital status, military or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), or other status protected by applicable law.
• Habitat Health is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Habitat Health will take steps to provide people with disabilities and sincerely held religious beliefs with reasonable accommodations in accordance with applicable law.

Contact Information

If you are interested in this position, please contact careers@habitat.com with “Habitat Health | Director, Accounting” and your name in the subject line. Please include a resume, and anything else that you feel will help us understand you and your interest in Habitat Health.