Medical Management Audit and Complaints Manager

Position Overview

Empower. Unite. Care. MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

Duties & Responsibilities

• Serve as the primary liaison for all external audits conducted by DOH, CMS, or other entities related to medical management or any functions connected to clinical services or operations.
• Cook up audit preparation, documentation collection, review of submitted documents and timely submission of required materials.
• Review audit findings, identify compliance gaps, and collaborate with departments to develop corrective action plans.
• Work with the medical management team to implement corrective actions that support sustained compliance and prevent recurrence.
• Manage the intake, triage, and investigation of clinically related complaints in accordance with regulatory timelines and organizational policies.
• Work with Medical Management departments to gather information and validate findings.
• Review departmental responses to ensure they clearly outline findings, corrective actions, and steps taken to resolve issues.
• Ensure complaint documentation meets regulatory and internal quality standards.
• Analyze audit and complaint data to identify trends, systemic issues, and opportunities for improvement.
• Prepare reports and present findings to leadership, highlighting risk and recommending process improvements.
• Partner with cross-functional teams to implement workflow changes and monitor the effectiveness of corrective actions.
• Provide guidance and training to staff and departments on audit processes, complaint management, and documentation best practices.

Minimum Qualifications

• Bachelor’s degree in healthcare administration, Nursing, Public Health, or related field.
• Minimum of 7 years’ experience in healthcare quality, compliance, medical management, or audit coordination.
• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED).
• Strong knowledge of NYS and CMS regulatory NYS standards.
• Demonstrated ability to identify opportunities for improvement & implement solutions.

Professional Competencies

• Excellent analytical, communication, and problem-solving skills.
• Ability to work cross-functionally and influence without direct authority
• Process improvement and Business Acumen
• Data-driven decision-making
• Ability to manage multiple priorities and work effectively across departments.
• Highly collaborative and demonstrating good judgment in seeking consensus & input from multiple stakeholders to drive decision-making
• Demonstrate understanding & acceptance of the MetroPlusHealth’s Mission, Vision, & Values