Manager, Medicaid Direct Investigations Position Available In Wake, North Carolina

Manager, Medicaid Direct Investigations 
Salary $67,852.00 – $118,741.00 Annually Location Wake County, NC Job Type Permanent Full-Time Remote Employment Flexible/Hybrid Job Number 25-05178 DHB 65005655 Department Dept of Health and Human Services Division

HEALTH BENEFITS

Opening Date 04/24/2025 Closing Date 5/1/2025 5:00 PM Eastern Job Class Title Human Services Program Manager II Position Number 65005655 Section C&PI Investigations Salary Grade

NC20 DESCRIPTION

BENEFITS
QUESTIONS
Description of Work This is an Internal Posting open ONLY for current DHHS employees and eligible RIF Candidates from NC State Government, To include eligible current Temporary Employees. Position is funded in part through federal funds.

• Position is Exempt from the State Human Resources Act – G.S. 126
• Position is eligible for a hybrid remote teleworking schedule to include weekly onsite work hours.
• The Medicaid Direct Investigations Manager provides operational leadership for state staff and vendors conducting prepayment and post-payment reviews to detect fraud, waste and abuse in the North Carolina Medicaid Direct program.

This position manages a team of professional investigators and analysts, with varied backgrounds who conduct claims and program compliance reviews to identify errors, incorrect payments, potential fraud, or billing abuse in the program.

Job responsibilities will include:

Facilitates the execution and maintenance of documented policies and procedures for NC Medicaid’s provider investigations operations. Ensures Medicaid Direct Team (MDT) staff and payment integrity vendor activities and processes align with Federal and state rules and regulations for provider investigations and related program integrity requirements. Facilitates monthly and quarterly vendor meetings to provide feedback to vendors on their performance of NC Medicaid payment integrity audits and investigations. Liaise with the Medicaid Investigations Division (MID), legal counsel (e.g., DHB Attorney, etc.) and others as necessary for expert consultation, clarification and/or approval of provider investigations and appeals strategies, to include escalation of high-priority concerns or violations Engage in personnel administration to include but not limited to recruiting, coaching, selecting, and managing employees, including disciplinary and termination actions as needed; delegating to staff members; encouraging and fostering professional development; establishing effective professional goals and work plan objectives. 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. About the NC Department of Health and Human Services (DHHS): 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.

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 website for benefits. Knowledge, Skills and Abilities / Competencies Listed below are the knowledge, skills and abilities (KSAs) associated with the position. These KSAs, along with the minimum education and experience listed, are required in order to be deemed “eligible” for the position therefore you must provide supporting information, within the body of your application, to demonstrate your possession of each KSA listed. Qualified applicants must possess, and application must clearly reflect work experience that demonstrates the following: Considerable knowledge of Special Investigation Unit activities and delivery systems. Considerable understanding of contract oversight and monitoring. Experience effectively managing personnel in the execution of provider audits and investigations. Strong analytical and problem-solving skills including data analytics to understand provider trends and/or issues. Experience managing personnel with diverse skill sets, and the ability to mentor employees. Proven ability to effectively supervise and motivate staff to accurately and effectively meet deadlines. Demonstrated ability to plan and organize work and be flexible and adaptable to continually changing priorities. Ability to develop and conduct staff training and program-wide presentations. Considerable knowledge of compliance monitoring, program reviews, resource management, appeals, records, and documentation. Management preference will be given to candidates: Thorough knowledge of North Carolina legislation regarding provider investigative processes and rights. Proven experience interpreting and consulting on North Carolina Medicaid provider policy. Experience leading a team of investigators and/or analysts. Minimum Education and Experience Requirements 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 Education and Experience Equivalency Guide for details. Master’s degree in a disciple specific to the program from an appropriately accredited institution and four years of experience in the area of assignment, including two years in a supervisory or consultative capacity; or OR
Bachelor’s degree in a discipline specific to the program from an appropriately accredited institution and six years of experience in the area of assignment, including two years in a supervisory or consultative capacity; or an equivalent combination of education and experience. OR
an equivalent combination of education and experience. Supplemental and Contact Information The North Carolina Department of Health and Human Services (DHHS) is an Equal Opportunity Employer who 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. It is critical to our screening and salary determination process that applications contain comprehensive information. Information should be provided in the appropriate areas to include the beginning and ending dates of jobs worked, education with the date graduated, all work experience, and certificates / licenses. Resumes will not be accepted in lieu of completing this application. Answers to Supplemental Questions must refer to education or work experience listed on this application to receive credit. Degrees must be received from appropriately accredited institutions. 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 a NGB 23A (RPAS) if they are a current member of the NC National Guard in good standing. If a former member of the NC National Guard, who served for at least 6 years and was discharged under honorable conditions, they must attach either a DD256 or NGB 22.
If applicants earned college credit hours but did not complete a degree program, they must attach an unofficial transcript to each application to receive credit for this education.
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. Applications for positions requiring specific coursework must be accompanied by a copy of the applicant’s transcript. Applicants with degrees not conferred at a United States college or university must attach verification that their degree is equivalent to a similar degree from a U.S. institution. The 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. Transcripts, degree evaluations and cover letters may be uploaded with your application.

NOTE:

Applicants will receive communication via email only for updates on the status of their application or any questions on their application. If there are any questions about this posting other than your application status, please contact Talent Acquisition at talentacquisition@dhhs.nc.gov. To check the status of an application, please log in to your NC Government Job Opportunities account and click “Application Status”.