Claims Manager, Audit & Complaints

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 operationsCoordinate audit preparation, assist with documentation collection, internal reviews, SME engagement, and timely submission of materialsReview 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 plansMonitor and manage corrective action plan implementation, ensuring milestone dates are metAfter correction action plans are implemented, periodically audit workflows and processes to ensure ongoing compliance and adherenceReview 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 configurationcorrections 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 enhancementsPartner 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 methodologiesExperience with Medicaid and Medicare products, particularly within New York StateDemonstrated ability to identify operational issues and implement effective, scalable solutions Professional Competencies Ability to work cross-functionally and influence without direct authorityExcellent analytical, problem solving, and data interpretation skillsDeep understanding of claims operations and regulatory requirementsProcess improvement and operational excellence mindsetExcellent written and verbal communication skillsAbility to manage multiple priorities in a fast-paced, evolving environmentHighly collaborative with strong stakeholder engagement and decision-making skillsDemonstrated sound judgment balancing compliance, operational, and business needsCommitment to MetroPlusHealth’s Mission, Vision, and Values #MHP50