About this opportunity
MetroPlus lists this Claims Manager, Audit & Complaints opportunity in new york, New York. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Position Overview
Reporting to the Director of Claims Quality, the Claims Manager, Audit & Complaints will oversee operational excellence and regulatory compliance by collaborating with cross‑departmental teams to ensure that claims‑related regulatory audits and complaints are thoroughly researched and addressed in a timely manner.
Scope of Role & Responsibilities
Working under the direction of and in collaboration with the Director of Claims Quality, the Claims Manager, Audit & Complaints will:
Act as a liaison for external audits conducted by DOH, CMS, and other regulatory entities related to claims operations
Coordinate audit preparation, assist with documentation collection, internal reviews, SME engagement, and timely submission of materials
Review audit findings and prepare an Executive Summary for Claims Leadership which identifies compliance gaps and deficiencies
Collaborate with Claims Leadership, Compliance, and upstream operational teams to develop corrective action plans
Monitor and manage corrective action plan implementation, ensuring milestone dates are met
After correction action plans are implemented, periodically audit workflows and processes to ensure ongoing compliance and adherence
Review Claims teams’ complaint triage findings, supporting documents and responses prior to submission to the team managing the complaint to ensure clarity, accuracy, and alignment with regulatory expectations
Working in collaboration with the Regulatory Complaints and the Complaints & Grievance teams, gather statistics of complaints related to claims adjudication errors or outcomes, track and trend. The Claims Manager, Audit & Complaints will:
Identify trends, root causes, and systemic issues impacting accurate claims adjudication and claims quality; collaborate with Claims leadership to identify systems fixes and configuration corrections needed
Ensure CPI and/or CRF tickets are submitted timely; monitor tickets to ensure timely implementation
Drive continuous improvement initiatives by translating findings into scalable process and product enhancements
Partner cross‑functionally to identify and suggest workflow changes to improve outcomes and quality results
Required Education, Training & Professional Experience
Bachelor’s degree from an accredited college or university in an appropriate discipline required
Master’s degree in business, healthcare or public administration preferred
Minimum 5-7 years experience in a health plan environment, with strong experience in claims operations, compliance, audit, or product management
Strong knowledge of claims lifecycle, adjudication processes, and reimbursement methodologies
Experience with Medicaid and Medicare products, particularly within New York State
Demonstrated ability to identify operational issues and implement effective, scalable solutions
Professional Competencies
Ability to work cross‑functionally and influence without direct authority
Excellent analytical, problem solving, and data interpretation skills
Deep understanding of claims operations and regulatory requirements
Process improvement and operational excellence mindset
Excellent written and verbal communication skills
Ability to manage multiple priorities in a fast‑paced, evolving environment
Highly collaborative with strong stakeholder engagement and decision‑making skills
Demonstrated sound judgment balancing compliance, operational, and business needs
Commitment to MetroPlusHealth’s Mission, Vision, and Values
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Worksite address
new york, NY, 10261, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.