Claims Manager, Audit & Complaints (Hiring Immediately)

Position Overview
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\nReporting 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
\nregulatory 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:

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• Act as a liaison for external audits conducted by DOH, CMS, and other regulatory entities related to claims operations
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• Coordinate audit preparation, assist with documentation collection, internal reviews, SME engagement, and timely submission of materials
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• Review audit findings and prepare an Executive Summary for Claims Leadership which identifies compliance gaps and deficiencies.
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• Collaborate with Claims Leadership, Compliance, and upstream operational teams to develop corrective action plans
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• Monitor and manage corrective action plan implementation, ensuring milestone dates are met
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• After correction action plans are implemented, periodically audit workflows and processes to ensure ongoing compliance and adherence
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• 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
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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
\nManager, Audit & Complaints will:

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• Identify trends, root causes, and systemic issues impacting accurate claims adjudication and claims quality. Collaborate with Claims leadership to identify systems fixes and configuration
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• corrections needed. Ensure CPI and or CRF tickets are submitted timely; monitor tickets to ensure timely implementation.
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• Drive continuous improvement initiatives by translating findings into scalable process and product enhancements
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• Partner cross-functionally to identify and suggest workflow changes to improve outcomes and quality results.
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Required Education, Training & Professional Experience

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• Bachelor’s degree from an accredited college or university in an appropriate discipline required.
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• Master’s degree in business, healthcare or public administration preferred.
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• Minimum 5-7 years experience in a health plan environment, with strong experience in claims operations, compliance, audit, or product management.
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• Strong knowledge of claims lifecycle, adjudication processes, and reimbursement methodologies
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• Experience with Medicaid and Medicare products, particularly within New York State
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• Demonstrated ability to identify operational issues and implement effective, scalable solutions
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Professional Competencies

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• Ability to work cross-functionally and influence without direct authority
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• Excellent analytical, problem solving, and data interpretation skills
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• Deep understanding of claims operations and regulatory requirements
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• Process improvement and operational excellence mindset
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• Excellent written and verbal communication skills
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• Ability to manage multiple priorities in a fast-paced, evolving environment
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• Highly collaborative with strong stakeholder engagement and decision-making skills
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• Demonstrated sound judgment balancing compliance, operational, and business needs
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• Commitment to MetroPlusHealth’s Mission, Vision, and Values
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