Associate Director, Provider Compliance

Health & Human Services; North Carolina; Hybrid; USD 76,000 - 148,000; Full time

Job summary

The North Carolina Department of Health and Human Services (DHHS) seeks a senior program manager to lead the Office of Compliance and Program Integrity. The role focuses on establishing and executing provider audits, investigations, and oversight across NC Medicaid contracted plans, ensuring compliance with CMS rules and state regulations.

Leadership, collaboration with analytics, and staff development are key responsibilities.

Qualifications

• Experience in leading and overseeing fraud, waste, and abuse detection in Medicaid or similar programs.
• Experience supervising staff, managing contractors, and vendor relationships.
• Strong data analysis and investigative planning skills.

Responsibilities

• Lead development of policies and procedures for provider audits and investigations.
• Oversee oversight of Special Investigations Units within managed care plans.
• Manage vendor audits and coordinate with other leaders for joint investigations.
• Enforce provider policies and corrective actions for identified violations.
• Ensure alignment with CMS rules and state requirements.
• supervise personnel, set goals, and support staff development.

Skills

FWA detection

Leadership

Data analysis

Policy compliance

Stakeholder collaboration

Project oversight

Tools

Microsoft Teams

Outlook

Excel

Word

Job description

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 Candidates now meet the minimum qualifications of a position if they meet the minimum education and experience listed on the vacancy announcement. 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.

Supplemental Contact Information: The North Carolina Department of Health and Human Services (DHHS) is an Equal Opportunity Employer that embraces an Employment First philosophy, which consists of complying with all federal laws, state laws, and Executive Orders. We are committed to reviewing requests for reasonable accommodation at any time during the hiring process or while on the job. For more information about DHHS: https://www.ncdhhs.gov/. DHHS uses the Merit-Based Recruitment and Selection Plan to fill positions subject to the State Human Resources Act with the most qualified individuals. Hiring salary will be based on relevant qualifications, internal equity, and budgetary considerations pertinent to the advertised position. In accordance with the Governor’s Executive Order 303, our agency supports second-chance employment for individuals who were previously incarcerated or justice-involved. We invite all potential applicants to apply for positions for which they may be qualified.

Minimum Education and Experience Some state job postings say you can qualify by an "equivalent combination of education and experience." If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details. Master’s degree in an area specific to the program from an appropriately accredited institution and five years of experience in the area of assignment, including three years in a supervisory or consultative capacity OR Bachelor’s degree in an area specific to the program from an appropriately accredited institution and seven years of experience in the area of assignment, including three years in a supervisory or consultative capacity OR An equivalent combination of education and experience.

EEO Statement The State of North Carolina is an Equal Employment Opportunity Employer and dedicated to providing employees with a work environment free from all forms of unlawful employment discrimination, harassment, or retaliation. The state provides reasonable accommodation to employees and applicants with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for religious beliefs, observances, and practices.

Recruiter: Lisa M Sasser Contact: DHHS Workday Support Form North Carolina State Government is one of the state’s largest employers, with over 76,000 employees all working toward a common goal: a safer and stronger North Carolina. We are a large organization comprised of various agencies, offices, and universities, each providing important public services. Eligible state employees are entitled to comprehensive benefits, including a variety of leave options, professional development opportunities, insurance, and more. To learn more about the benefits of being a North Carolina state employee, visit the N.C. Office of State Human Resources' website. Permanent, temporary, and time-limited state government jobs can be found from the mountains to the coast. Find your next opportunity today! State Application Resources/Frequently Asked Questions Valuing Education and Experience The State of North Carolina values the knowledge and experience of our jobseekers and current state employees. Approximately 91 percent of state job classifications allow experience to be substituted for education or do not require a post-secondary degree. Learn more about how you may qualify for a position through education or directly related experience, or a combination of both, with the Education and Experience Equivalency Guide. All job postings close at 11:59pm the night before the End Date on the posting. Introduce yourself to our recruiters and we’ll get in touch if there’s a role that seems like a good match. If you are already a state employee, please search for jobs by clicking here.