Program Integrity Coordinator

Program Coordinator IV (NS)

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.

In North Carolina Medicaid, County Departments of Social Services perform the Medicaid program integrity function under the oversight of the State Medicaid agency. Under the Social Security Act, Title XIX, Section 1909 and the Federal Regulations 42 CFR Part 455 entitled Program Integrity-Medicaid states the requirements for the control of fraud and abuse in the Medicaid program by the state Medicaid agency. The employee conducts preliminary reviews and investigation referrals of member fraud, waste, and abuse stemming from complaints received from citizens, legislators, Office of Inspector General (OIG), and Prepaid Health Plans (PHP). Employee conducts compliance monitoring of County DSS Fraud Plans via on-site monthly visits. Employee conducts reviews of DSS Program Integrity processes and procedures to ensure compliance, efficiency, and accountability with identifying and addressing allegations of member fraud, waste, and abuse in accordance with federal requirements and state statutes. Employee implements the Centers for Medicare and Medicaid Services (CMS) fraud, waste, and abuse initiatives. Employee follows state and federal (CMS) regulations for quality control reviews, systematically reviews and evaluates test cases, and documents review findings for each case in a state database. Employee verifies eligibility factors for members through contacts with businesses, federal and state agencies, and individuals with knowledge specific to the member. Employee reviews county performance reports and conducts follow-up with appropriate county staff, as well as: develops training webinars and modules for county Program Integrity staff; provides trainings and education at conferences, area meetings, and by phone; stays informed with policy changes and accuracy standards. Employee participates in work groups to create uniformity and standardization on specific processes and formats for all Health Plan Special Investigative Units (SIU). Employee is responsible for implementing the State PI Compliance Monitoring Plan by conducting monthly compliance reviews based on the plan scope and conducts collaborative compliance monitoring exit meetings with the county Program Integrity departments based on the Compliance Monitoring Plan scope.

Salary Grade Range $52,592 - $92,036

Recruitment Range $52,592 - $66,675

Position is 100% remote

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:

• Considerable understanding of social services and Medicaid program areas, along with general awareness of agency programs impacting North Carolina residents.
• Ability to research, analyze, and interpret Federal and State laws and translate them into policies governing social services and Medicaid programs.
• Working knowledge of the NCFAST eligibility system and its role in program operations.
• Proven ability to establish and maintain effective working relationships with Federal, State, and local agencies, beneficiaries, the public, and private service providers.
• Experience in compliance monitoring, ensuring regulatory adherence, and demonstrating strong analytical, oral, and written communication skills.

Management Preferences:

• Previous and proven work experience as a Medicaid eligibility caseworker or program integrity investigator.
• Working experience with NCTRACKS.
• Working experience with NCFAST.

Physical Requirements:

Fingering: Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand or arm as in handling.

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

Position is funded in part through federal funds

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.

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.