Claims Audit & Compliance Manager

MetroPlus; New York (NY); On-site; USD 110,000 - 140,000; Full time

Job summary

MetroPlusHealth is seeking a Claims Manager, Audit & Complaints to oversee regulatory audits and complaint handling within claims operations. The role collaborates across departments to ensure timely research, resolution, and ongoing compliance with governing agencies.

Responsibilities include coordinating with DOH, CMS, and internal teams, drafting executive summaries, and leading corrective action implementation to drive continuous improvement in claims quality.

Qualifications

• Bachelor’s degree required in an appropriate discipline.
• Master’s degree in business, healthcare, or public administration preferred.
• Minimum 5–7 years experience in a health plan environment, with strong claims operations, compliance, audit, or product management background.
• Strong knowledge of claims lifecycle, adjudication processes, and reimbursement methodologies.
• Experience with Medicaid and Medicare products, particularly within New York State.

Responsibilities

• Act as a liaison for external audits by DOH, CMS, and other regulatory entities related to claims operations.
• Coordinate audit preparation, documentation collection, internal reviews, SME engagement, and timely submission of materials.
• Review audit findings and prepare an Executive Summary identifying compliance gaps and deficiencies.
• Collaborate with Claims Leadership, Compliance, and upstream teams to develop corrective action plans.
• Monitor corrective action plan implementation and ensure milestone dates are met.
• Periodically audit workflows to ensure ongoing compliance after corrective actions.
• Review complaint triage findings and responses for clarity and regulatory alignment.

Skills

Cross-functional

Analytical thinking

Regulatory knowledge

Claims operations

Communication skills

Education

Bachelor’s degree

Master’s degree preferred

Job description

MetroPlusHealth is seeking a Claims Manager, Audit & Complaints to oversee regulatory audits and complaint handling within claims operations. The role collaborates across departments to ensure timely research, resolution, and ongoing compliance with governing agencies.

Responsibilities include coordinating with DOH, CMS, and internal teams, drafting executive summaries, and leading corrective action implementation to drive continuous improvement in claims quality.