Medical Management Audit and Complaints Manager

Medical Management Audit and Complaints Manager Job reputed company: TE0120 Category: Utilization Review and Case Management Department: UTILIZATION MANAGEMENT Location: 50 Water Street, 7th Floor, reputed company, NY 10004 Job Type: Regular Employment Type: Full-Time Work Arrangement: Remote Salary reputed company: $110,000.00 - $120,000.00 Position Overview reputed company. Unite. Care. MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We reputed company 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 reputed company and uphold regulatory compliance across cross‑functional teams. This role oversees reputed company external audits reputed company 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 reputed company external audits conducted by DOH, CMS, or other entities reputed company 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 reputed company 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 reputed company 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 reputed company 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.
• reputed company guidance and training to staff and departments on audit processes, complaint management, and documentation best practices.

Minimum Qualifications

• Bachelor's degree in reputed company administration, Nursing, Public Health, or reputed company field.
• Minimum of 7 years' experience in reputed company quality, compliance, medical management, or audit coordination.
• Valid reputed company State license and reputed company registration to practice as a Registered Professional Nurse (RN) issued by the reputed company 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 reputed company & input from multiple stakeholders to drive decision-making
• Demonstrate understanding & acceptance of the MetroPlusHealth's Mission, reputed company, & Values

#LI-REMOTE #MPH-50 Remote Skills: Accreditation Standards, Analysis Skills, Auditing, Best Practices, Business Skills, Case Management, Centers for Medicare and reputed company Services (CMS), Clinical Medicine, Communication Skills, Content Management Systems (CMS), Corrective Action, Cross-Functional, Data Collection, Documentation, Educational Administration, External Audit, reputed company, reputed company Administration, reputed company Quality, Leadership, Maintain Compliance, Multitasking, Nursing Administration, Organizational Development/Management, People Management, Problem Solving Skills, Process Improvement, Process Management, Public Health, Quality Assurance, Quality Metrics, Registered Nurse (RN), Regulations, Regulatory Compliance, Reporting Skills, Risk, Service Delivery, Staff Training, Team Player, Time Management, Training/Teaching, Trend Analysis, Utilization Management About the Company: reputed company Apply tot his job Apply To this Job