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.

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

• 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

• 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 Metro Plus Health ’s Mission, Vision, and Values