Manager, Part C & Authorizations

Habitat Health

6d•$119,000 - $134,000

About The Position

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 looking to shape a vital subfunction at our organization. This role ensures 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.

Requirements

7+ 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).

Nice To Haves

PACE experience strongly preferred.
Master’s degree preferred.

Responsibilities

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 reports that will support the efficacy of each service authorizations process activity and to produce a summary at least annually or upon request that includes statistical reports of activity, quality improvement activities, and utilization outcomes.
Review and monitor encounter data submissions for accuracy, ensuring discrepancies are identified, corrected, and communicated through collaboration with cross functional teams; maintain 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.
Conduct 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.