Associate Director, Provider Compliance

Agency

Dept of Health and Human Services

Division

HEALTH BENEFITS

Job Classification Title

Human Services Program Manager III (NS)

Position Number

60042687

Grade

NC22 About Us

The North Carolina Department of Health and Human Services (DHHS) is one of the largest, most complex agencies in the state, and has approximately 17,000 employees. It is responsible for ensuring the health, safety, and well-being of all North Carolinians, providing human service needs for special populations including individuals who are deaf, blind, developmentally disabled, and mentally ill, and helping poor North Carolinians achieve economic independence.

Description of Work

The NC Medicaid Office of Compliance and Program Integrity (OCPI) monitors the Medicaid community (beneficiaries, providers, vendors and internal staff) for compliance with state and federal regulations and potential fraud, abuse and neglect. OCPI verifies dollars are paid appropriately for covered services by using claim reviews and investigations, implementing recoveries, pursuing recoupments and aggressively identifying other opportunities for cost avoidance.

The Associate Director, Provider Compliance is a senior management position responsible for assisting the Deputy Director/Chief Compliance Officer in key activities of DHB’s Office of Compliance and Program Integrity unit. This position will be responsible for establishing and executing effective oversight protocols of the Special Investigations Units of the State’s contracted health plans while developing and implementing procedures for conducting provider audits and investigations in accordance with all federal and state rules and regulations to reduce provider fraud, waste and abuse. This position will ensure NC Medicaid managed care organizations have and follow sound principles and practices for conducting provider audits, investigations and monitoring. This role will work in partnership with DHB Provider Operations and DHB Clinical Policy to facilitate the adequate implementation of provider policies and practices which lead to compliance with Centers for Medicare & Medicaid Services (CMS) rules and guidelines and North Carolina legislative requirements for Medicaid providers.

Key

Duties

• Include

• Lead the development, maintenance and execution of documented policies and procedures for the establishment of OCPI’s provider audits and investigations protocol to prevent illegal, unethical, or improper payment of Medicaid dollars.

• Lead the development, maintenance and execution of documented policies and procedures for NC Medicaid’s approach to effective oversight and monitoring of the State’s contracted Managed Care Plans’ Special Investigations Units.

• Oversee the scope of work development and execution of vendors conducting provider audits and investigations under OCPI responsibility and liaise with other business unit leaders for joint provider audit and investigations efforts.

• Enforce provider policies and procedures to include the use of standardized investigations and corrective actions to address identified and reported violations.

• Ensure that the processes and procedures are aligned with authorized enforcement authorities.

• Develop and perform and/or authorize periodic provider audit initiatives to ensure that compliance with clinical and payment policies is being achieved and that the compliance program is relevant and up to date with the needs and requirements of DHB and CMS.

• Successfully liaise and collaborate with OCPI Compliance Analytics, Medicaid Investigations Division (MID), legal counsel (e.g., DHB Attorney, etc.) and others as necessary for expert consultation, clarification and/or approval of provider compliance-based initiatives and interests, to include escalation of high-priority concerns or violations and prosecutions.

• Measure and report on operational performance and lead the development of plans to improve relevant key performance indicators within the Provider Compliance unit.

• Engage in personnel administration to include but not limited to recruiting, selecting, and managing employees; delegating to staff members; encouraging and fostering professional development; establishing effective professional goals and work plan objectives.

• Knowledge Skills and Abilities/Management Preferences

• Salary Grade Range: $75,925.00 - $148,054.00

• Recruitment Range $75,925.00 - $110,000.00

• The Knowledge, Skills, and Abilities (KSAs)/ Management Preferences are not required. Applicants who possess the following skills are preferred:

• Expertise in leading and overseeing fraud, waste, and abuse (FWA) detection, prevention, and investigative activities within Medicaid, managed care, or other healthcare programs, including the application of state and federal regulations to support program integrity and compliance efforts.

• Demonstrated experience managing complex investigations, provider audits, and compliance reviews, including evaluating evidence, identifying potential violations, preparing referrals, supporting criminal or civil proceedings, and developing investigative strategies based on data analysis and program findings.

• Documented experience supervising professional staff, contractor personnel, and vendor relationships, including workload management, performance evaluation, coaching, employee development, vendor monitoring, and ensuring timely achievement of program objectives and regulatory requirements.

• Skilled in building and maintaining collaborative partnerships with law enforcement agencies, prosecutorial authorities, healthcare providers, managed care organizations, government agencies, and other stakeholders to support investigations, compliance activities, and program integrity initiatives.

• Advanced proficiency using Microsoft Teams, Outlook, Excel, Word, and related business applications to analyze and report data, prepare investigative and audit documentation, communicate findings, negotiate resolutions, and present complex information to diverse audiences in a clear and effective manner.

• REPOST - Previous Applicants Do Not Need To Reapply In Order To Be Considered For This Vacancy

• The Posting Will Close At 11:59 P.M. The Night Before The End Date

• This Position Is Funded In Part Through Federal Funds

• This Position Is Eligible For A Hybrid Work Option

About the NC Division of Health Benefits:

• The Division of Health Benefits (DHB) within NCDHHS is committed to advancing innovative solutions that improve health, promote well-being and foster independence for all North Carolinians. DHB manages and oversees North Carolina Medicaid and other programs that provide access to services and supports for parents, children, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders. With a budget over $27 billion in state and federal funds per fiscal year, DHB ensures that more than 108,000 enrolled providers are reimbursed for delivering covered services to 3.1 million beneficiaries.

• All positions in the Division of Health Benefits are exempt from the State Human Resources Act (G.S. 126) except for the provisions of Articles 6 and 7 per HB 372 Section 20.

Compensation and Benefits:

• The State of North Carolina offers excellent comprehensive benefits. Employees can participate in health insurance options, standard and supplemental retirement plans, and the NCFlex program (numerous high-quality, low-cost benefits on a pre-tax basis). Employees also receive paid vacation, sick, and community service leave. In addition, paid parental leave is available to eligible employees.

• Visit the website for State Benefits.