Medical Management Audit and Complaints Manager

Job Ref: TE0120
Category: Utilization Review and Case Management
Department: UTILIZATION MANAGEMENT
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Work Arrangement: Remote
Salary Range: $110,000.00 - $120,000.00

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.

Reporting to the Vice President of Clinical Services, with a dotted-line relationship to the Product team, the Medical Management Audit and Complaints Manager partners with the newly established SWAT Audit and Complaints arm of the SWAT unit to advance operational excellence and uphold regulatory compliance across cross‑functional teams. This role oversees all external audits related to service delivery and clinical operations, while also leading the investigation and resolution of clinically focused complaints.  The Medical Management Audit and Complaints Manager ensure adherence to regulatory and accreditation standards, drives quality‑improvement initiatives, and reinforces accountability throughout clinical departments. This individual provides expert guidance, analyze trends, and recommends process improvements to strengthen organizational performance.

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.
• Coordinate 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

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