Lead Managed Care Investigator

State of North Carolina

1d • Hybrid

About The Position

The Lead Managed Care Investigator plays a critical role in ensuring quality and compliance within the Medicaid program. This position is responsible for providing oversight of vendors and Managed Care Organizations (MCOs), supporting investigations, and engaging in audit activities. This role involves collaboration with local non-governmental entities, the Attorney General’s Office (AGO), and other oversight partners, as well as coordination with service providers. Additional responsibilities include staff technical support, quality assurance of work, and providing support for various operational needs. This position also serves as a subject matter expert (SME) in consultations with management and team members regarding Medicaid policies and procedures involving OCPI functions and other administrative matters.

Requirements

• Licensed to practice as a Registered Nurse in the State of North Carolina and two years of clinical experience in the area of specialization.

Nice To Haves

• Working knowledge of Medicaid program objectives, clinical billing, medical coding, documentation standards, and state/federal regulatory requirements, including certifying and accrediting body standards.
• Ability to interpret and apply state and federal regulations, managed care contracts, provider standards, and program policies to ensure compliance across statewide program components.
• Skilled in data collection, analysis, program evaluation, quality assurance, investigative techniques, and conducting audits and documentation reviews.
• Strong communication skills, both oral and written, with experience explaining policy, delivering training, and collaborating effectively with agencies, providers, and diverse stakeholder groups.
• Highly organized with the ability to plan, prioritize, and manage daily assignments, supported by proficiency in Microsoft Office applications to produce high‑quality deliverables.
• Experience interpreting and consulting on clinical policy.
• Experience working with managed care organizations that includes investigative audits and reporting asks.
• Experience performing investigations to establish Fraud, Waste, and Abuse credibility.

Responsibilities

• Providing oversight of vendors and Managed Care Organizations (MCOs)
• Supporting investigations
• Engaging in audit activities
• Collaboration with local non-governmental entities, the Attorney General’s Office (AGO), and other oversight partners
• Coordination with service providers
• Staff technical support
• Quality assurance of work
• Providing support for various operational needs
• Serving as a subject matter expert (SME) in consultations with management and team members regarding Medicaid policies and procedures involving OCPI functions and other administrative matters.

Benefits

• Eligible state employees are entitled to comprehensive benefits, including a variety of leave options, professional development opportunities, insurance, and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 1,001-5,000 employees