Medicaid Compliance Investigator II

State of North Carolina - Health & Human Services; North Carolina; Hybrid; USD 67,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

State of North Carolina - Health Benefits is seeking a Nurse Consultant II (NS) to join the Office of Compliance and Program Integrity in a hybrid role serving NC Medicaid investigations. The Clinical Investigator II conducts investigations of Medicaid claims, encounters and medical records to ensure compliance with state and federal rules, applying reimbursement rules and RAC concepts.

The ideal candidate is a licensed Registered Nurse with strong analytical skills and experience interpreting

Qualifications

• Licensed to practice as a Registered Nurse and two years of clinical experience in the area of specialization.
• Experience applying Medicaid coverage policies, reimbursement methodologies, and adjudication standards.
• Ability to interpret medical terms, codes, and records to support clinical investigations.

Responsibilities

• Conduct investigations of Medicaid claims, encounters, financial records, and medical documentation to assess compliance and accountability.
• Review RAC concepts against policies and reimbursement rules to recommend dispositions before audit initiation.
• Validate RAC findings by comparing vendor outputs with policies and payment rules.
• Manage secure file transfers with Medicaid, RAC vendors, and fiscal agents; resolve technical errors.
• Prepare written summary reports documenting findings, conclusions, and dispositions for investigative cases.

Skills

RN license

Investigative skills

Attention to detail

Education

RN License

Job description

State of North Carolina - Health Benefits is seeking a Nurse Consultant II (NS) to join the Office of Compliance and Program Integrity in a hybrid role serving NC Medicaid investigations. The Clinical Investigator II conducts investigations of Medicaid claims, encounters and medical records to ensure compliance with state and federal rules, applying reimbursement rules and RAC concepts.

The ideal candidate is a licensed Registered Nurse with strong analytical skills and experience interpreting