Associate Director, Provider Compliance

State of North Carolina•Wake Forest, NC

5d•$75,925 - $148,054•Hybrid

About The Position

The Associate Director, Provider Compliance is a senior management position in the NC Medicaid Office of Compliance and Program Integrity (OCPI). The position assists the Deputy Director/Chief Compliance Officer with key activities and establishes and executes oversight protocols for the Special Investigations Units of the State’s contracted health plans. It develops and implements provider audit and investigation procedures in accordance with federal and state requirements to reduce provider fraud, waste, and abuse. The role ensures that NC Medicaid managed care organizations follow sound practices for provider audits, investigations, and monitoring. It works with DHB Provider Operations and DHB Clinical Policy to support implementation of provider policies and practices consistent with CMS rules and guidelines and North Carolina legislative requirements. The position is eligible for a hybrid work option and is funded in part through federal funds.

Requirements

Master’s degree in a program-specific area 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 a bachelor’s degree in a program-specific area 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.

Nice To Haves

Expertise leading and overseeing fraud, waste, and abuse detection, prevention, and investigations in Medicaid, managed care, or other healthcare programs, including applying state and federal regulations.
Experience managing complex investigations, provider audits, and compliance reviews, including evaluating evidence, identifying potential violations, preparing referrals, supporting criminal or civil proceedings, and developing data-informed investigative strategies.
Experience supervising professional staff, contractor personnel, and vendor relationships, including workload management, performance evaluation, coaching, employee development, vendor monitoring, and ensuring timely delivery of program objectives and regulatory requirements.
Skill in developing collaborative partnerships with law enforcement, prosecutorial authorities, healthcare providers, managed care organizations, government agencies, and other stakeholders.
Advanced proficiency with Microsoft Teams, Outlook, Excel, Word, and related business applications for analyzing and reporting data, preparing investigative and audit documents, communicating findings, negotiating resolutions, and presenting complex information.

Responsibilities

Lead the development, maintenance, and execution of documented policies and procedures for OCPI provider audit and investigation protocols to prevent illegal, unethical, or improper Medicaid payments.
Lead the development, maintenance, and execution of policies and procedures for oversight and monitoring of contracted Managed Care Plans’ Special Investigations Units.
Oversee the development and execution of scopes of work for vendors conducting provider audits and investigations under OCPI responsibility, and coordinate joint audit and investigation efforts with other business unit leaders.
Enforce provider policies and procedures, including standardized investigations and corrective actions for identified and reported violations.
Ensure processes and procedures align with authorized enforcement authorities.
Develop and conduct, or authorize, periodic provider audit initiatives to assess compliance with clinical and payment policies and ensure the compliance program remains relevant and current.
Collaborate with OCPI Compliance Analytics, the Medicaid Investigations Division, legal counsel, and other stakeholders for consultation, clarification, or approval of provider compliance initiatives; escalate high-priority concerns or violations and prosecutions as needed.
Measure and report operational performance and lead plans to improve Provider Compliance unit key performance indicators.
Recruit, select, and manage employees; delegate work; foster professional development; and establish professional goals and work plan objectives.