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.

Job Specific Responsibilities:
• 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

Recruitment Range $100,641 - $107,816

**Position is eligible for a hybrid-teleworking schedule to include weekly onsite work hours**

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:

• Deep expertise in detecting and preventing fraud, waste, and abuse (FWA) within Medicaid and managed care, supported by the ability to translate data insights into actionable investigative strategies.

• Proven ability to lead complex investigations, analyze evidence, prepare cases for referral, and support criminal or civil proceedings while ensuring compliance with state and federal regulations.

• Demonstrated leadership experience managing large teams, overseeing vendor relationships, and fostering collaboration across internal and external stakeholders.

• Skilled in building and maintaining effective partnerships with law enforcement, prosecutorial agencies, providers, and health plans, supported by exceptional written and verbal communication for reports, presentations, and negotiations.

• Strong proficiency in Microsoft Office applications (Teams, Outlook, Excel, Word) with the ability to coach staff, manage performance, and coordinate high‑impact investigative and program activities.

Management Preferences:

• Previous work experience with a Medicaid agency.

• Experience effectively managing personnel in the execution of provider audits and investigations.

• Considerable knowledge of healthcare operations.

• Familiarity with state of NC contracting processes, including vendor monitoring.

Posting closes at 11:59 p.m. the night before the closing date

Position is funded in part through federal funds

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.

Compensation & 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 website for State Benefits

Supplemental and 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.

               

Application Process
Be sure to complete the application in its entirety.   Resumes will not be accepted in lieu of completing this application. 

• Information should be provided in the appropriate areas, to include the following: Education, including high school and all degrees obtained, Work Experience, and Certificates & Licenses. It is critical to our screening and salary determination process that applications contain comprehensive candidate information.

• Answers to Supplemental Questions are not a substitute for providing all relevant information within the body of your application. To receive credit for the supplemental questions, you must provide supporting information within the "Work Experience" section of the application to support your answers.

• If multiple applications are submitted to an individual posting, only the most recent application received prior to the closing date will be accepted. Applications must be submitted by 11:59 PM the night BEFORE the closing date.

• Applicants may be subject to a criminal background check. All candidates selected for positions considered "Positions of Trust" will be subject to a criminal background check.

• Due to the volume of applications received, we are unable to provide information regarding the status of your application over the phone. To check the status of your application, please log in to your account.  Upon the closing date, applications are "Under Review" and will be screened by Human Resources for qualified applicants. The hiring process may take several weeks.

• Degrees must be received from appropriately accredited institutions.  Transcripts and degree evaluations may be uploaded with your application. The State of North Carolina/Office of State Human Resources uses the National Association of Credential Evaluation Services (NACES) as a referral resource for applicants who need to have their credentials certified as equivalent.

• For a list of organizations that perform this specialized service, please visit the NACES membership website at https://www.naces.org/members. 

Degree/College Credit Verification

Degrees must be received from appropriately accredited institutions.  Transcripts, degree evaluations and cover letters may be uploaded with your application.

Veterans’ and National Guard Preference

• Applicants seeking Veteran's Preference must attach a DD-214 Member-4 Form (Certificate of Release or Discharge from Active Duty) to their applications.

• Applicants seeking National Guard Preference must attach an NGB 23A (RPAS), along with the state application, if they are a current member of the NC National Guard in good standing. 

• Applicants who are former members of either the NC Army National Guard or the NC Air National Guard, with honorable discharge and six years of creditable service, must attach a copy of the DD 256 or NGB 22, along with the state application.

ADA Accommodations

Consistent with the Americans with Disabilities Act (ADA) and the Pregnant Workers Fairness Act (PWFA), DHHS is committed to the full inclusion of all qualified individuals. As part of this commitment, DHHS will ensure that people with disabilities, or known limitations covered by the PWFA, are provided with reasonable accommodation.  If reasonable accommodation is needed to participate in the job application or interview process, please contact the person Substance Abuse Professional Practice Board, etc.) indicated below.

CONTACT INFORMATION: 

If there are any questions about this posting, please contact Talent Acquisition at talentacquisition@dhhs.nc.gov. Resumes will not be accepted in lieu of completing this application.

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.

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:

Tandrea Lanae Jones

Email:

talentacquisition@dhhs.nc.gov