Clinical Investigator II

Adult Correction; North Carolina; Hybrid; USD 67,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

Adult Correction in North Carolina seeks a Clinical Investigator II to support the Office of Compliance and Program Integrity (OCPI) by conducting Medicaid investigations and ensuring compliance with state and federal rules. The role focuses on detecting fraud, abuse, and overutilization, with RAC activities and proper audit handling.

The position requires reviewing medical documentation and coding, applying reimbursement rules, and coordinating secure data exchanges with vendors.

Qualifications

• Demonstrated experience applying the investigative process to detect, analyze, and document Medicaid fraud, abuse, overutilization, and related compliance issues.
• Experience reviewing and interpreting medical, dental, and behavioral health terminology, disease processes, diagnostic procedures, and treatments at an intermediate or higher proficiency level to support clinical investigations.
• Proven experience evaluating medical records, medical codes, and claims processing rules to determine compliance with Medicaid coverage policies, reimbursement methodologies, and adjudication standards.
• Track record of applying state and federal standards, certifying and accrediting body requirements, and quality assurance principles to assess program integrity and support investigative decisions.
• Documented experience training and coaching team members by evaluating work accuracy, providing constructive feedback, and explaining investigative or policy‑related procedures clearly.

Responsibilities

• Conduct investigations of Medicaid claims, encounters, financial records, and medical documentation to assess compliance, efficiency, and accountability.
• Apply Medicaid coverage policies, State and Federal regulations, reimbursement methodologies, and payment rules when evaluating investigative findings.
• Review RAC concepts against clinical coverage policies, reimbursement methodologies, and adjudication rules to recommend disposition prior to audit initiation.
• Validate RAC findings by comparing vendor outputs against approved concepts, policies, and applicable payment rules.
• Manage secure file transfers for Medicaid, RAC vendors, and the fiscal agent, resolving technical file-related errors.
• Conduct provider investigation activities according to NC Medicaid's procedures.
• Compile and analyze information from various sources to support investigative conclusions.
• Prepare written summary reports documenting findings, conclusions, and dispositions for investigative cases.
• Identify fraud, abuse, and overutilization patterns and report concerns appropriately.

Skills

Investigative process

Medicaid terminology

Medical records review

Regulatory standards

Team coaching

Job description

Agency

Dept of Health and Human Services

Division

HEALTH BENEFITS

Job Classification Title

Nurse Consultant II (NS)

Position Number

60042874

Grade

MH17

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 Clinical Investigator II supports the Office of Compliance and Program Integrity (OCPI) by conducting investigations of Medicaid claims, encounters, payment data, financial information, and medical record documentation to ensure compliance with state and federal regulations.

This position verifies that Medicaid dollars are paid appropriately by applying Medicaid coverage policies, reimbursement rules, participation agreements, and contractual requirements to investigative findings. It performs professional investigative work to detect, investigate, and report potential fraud, abuse, and overutilization involving Medicaid and Health Choice providers and beneficiaries.

The Clinical Investigator II also serves as the primary facilitator for federally required Recovery Audit Contractor (RAC) activities, ensuring proper evaluation of proposed concepts and audit findings. This position contributes to OCPI's mission of ensuring efficiency, accountability, and appropriate use of Medicaid funds.

Key Duties Include:

• Conduct investigations of Medicaid claims, encounters, financial records, and medical documentation to assess compliance, efficiency, and accountability.
• Apply Medicaid coverage policies, State and Federal regulations, reimbursement methodologies, and payment rules when evaluating investigative findings.
• Review proposed Recovery Audit Contractor (RAC) concepts against clinical coverage policies, reimbursement methodologies, and adjudication rules to recommend disposition prior to audit initiation.
• Validate completed RAC findings by comparing vendor outputs against approved concepts, documented policies, and applicable payment rules.
• Manage secure file transfer exchanges for Medicaid, RAC vendors, and the fiscal agent, including resolution of technical file-related errors.
• Conduct provider investigation activities according to NC Medicaid's documented provider investigation procedures.
• Compile and analyze information and statistics from various documentation sources to support investigative conclusions.
• Prepare written summary reports that document findings, conclusions, and recommended dispositions for investigative cases.
• Identify potential fraud, abuse, and overutilization patterns by reviewing investigative data and reporting concerns appropriately.
• Support OCPI's cost‑avoidance and risk‑management efforts by implementing recoveries, pursuing recoupments, and identifying opportunities for improved payment integrity.

Knowledge Skills and Abilities/Management Preferences

Salary Grade Range: $66,696.00 - $110,049.00

Recruitment Range: $66,696.00 - $81,694.00

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:

• Demonstrated experience applying the investigative process to detect, analyze, and document Medicaid fraud, abuse, overutilization, and related compliance issues.
• Experience reviewing and interpreting medical, dental, and behavioral health terminology, disease processes, diagnostic procedures, and treatments at an intermediate or higher proficiency level to support clinical investigations.
• Proven experience evaluating medical records, medical codes, and claims processing rules to determine compliance with Medicaid coverage policies, reimbursement methodologies, and adjudication standards.
• Track record of applying state and federal standards, certifying and accrediting body requirements, and quality assurance principles to assess program integrity and support investigative decisions.
• Documented experience training and coaching team members by evaluating work accuracy, providing constructive feedback, and explaining investigative or policy‑related procedures clearly.

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

EHRA: Per G.S. 126-5(c1) (37), This Position Is EXEMPT From All Provisions Of NC General Statute Chapter 126 (State Human Resources Act) With The Exception Of Articles 6 And 7

RN License Must Be Provided On The Application

Physical Requirements:

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