Senior Claims Audit & Compliance Leader

MetroPlusHealth; New York (NY); On-site; USD 120,000 - 170,000; Full time

Job summary

MetroPlusHealth is seeking a Claims Manager, Audit & Complaints to lead regulatory audits and complaint responses within the Claims Quality program. The role partners with cross-functional teams to ensure timely research, documentation, and remediation of identified issues.

The ideal candidate has 5–7 years in a health plan environment with deep knowledge of Medicaid/Medicare claims, lifecycle, and compliance. Strong analytical and communication skills are essential.

Qualifications

• Bachelor’s degree required.
• Master’s degree preferred.
• 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.

Responsibilities

• Act as 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 identifying 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.
• Periodically audit workflows and processes after correction actions are implemented to ensure ongoing compliance.
• Review Claims teams’ complaint triage findings, supporting documents and responses prior to submission to the team managing the complaint.
• 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.

Skills

Regulatory compliance

Audit management

Cross-functional collaboration

Data interpretation

Claims lifecycle

Analytical skills

Communication skills

Education

Bachelor's degree

Master's degree (preferred)

Job description

MetroPlusHealth is seeking a Claims Manager, Audit & Complaints to lead regulatory audits and complaint responses within the Claims Quality program. The role partners with cross-functional teams to ensure timely research, documentation, and remediation of identified issues.

The ideal candidate has 5–7 years in a health plan environment with deep knowledge of Medicaid/Medicare claims, lifecycle, and compliance. Strong analytical and communication skills are essential.