Lead Nurse Consultant

State of North Carolina

2d • Hybrid

About The Position

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. The North Carolina Medicaid Office of Compliance and Program Integrity (OCPI) monitors the Medicaid community—including beneficiaries, providers, vendors, and internal staff—for compliance with state and federal regulations, as well as potential fraud, abuse, and neglect. OCPI ensures that Medicaid dollars are paid appropriately for covered services through claim reviews, investigations, recoveries, and recoupments while identifying opportunities for cost avoidance and risk management. This position serves as a senior-level clinical and investigative consultant within OCPI and leads the end-to-end payment analytics and clinical audit process. The role works collaboratively with external vendors and internal partners to ensure Medicaid payments are accurate, policy-compliant, and recoverable when necessary. The incumbent applies advanced clinical judgment, regulatory expertise, and investigative skill to oversee claim audits, manage appeals, and strengthen program integrity and operational efficiency across the Medicaid system.

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

• Advanced knowledge of clinical practices, Medicaid policies, and healthcare regulations related to program integrity and compliance.
• Demonstrated experience leading complex audits, investigations, or program reviews requiring analytical evaluation and professional judgment.
• Strong ability to interpret and apply state and federal Medicaid regulations and communicate findings effectively to diverse audiences.
• Proven skill in coordinating work across multiple stakeholders, including vendors, legal partners, and internal leadership.
• Exceptional attention to detail, organization, and time management with the ability to meet deadlines in a fast-paced environment.

Responsibilities

• Lead and manage the payment audit and analytics lifecycle in partnership with external vendors and internal OCPI staff to ensure compliance with Medicaid policy and regulations.
• Facilitate the bimonthly audit concept and approval process, ensuring alignment with program priorities and clinical objectives.
• Oversee claim selection, validation, and approval processes, including review of selection files, error resolution, and case documentation.
• Manage provider communication workflows, including letter approvals, invoice reconciliations, offsets, collections, and repayments.
• Serve as OCPI’s primary contact for reconsiderations and appeals, coordinating with the DHHS Appeals Section and Department of Justice (DOJ) to ensure appropriate resolution.
• Provide clinical consultation and policy interpretation throughout the audit and appeals process, including participation in Office of Administrative Hearings (OAH) proceedings.
• Maintain oversight of all case documentation, audit tools, and vendor deliverables to ensure accuracy, completeness, and compliance with regulatory standards.
• Identify and implement process improvements to enhance audit efficiency, provider engagement, and cost recovery outcomes.
• Collaborate with Medicaid leadership to support data-driven decision-making, risk management, and quality improvement initiatives.

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