Managed Care Oversight Investigator I

State of North Carolina

1d • $50,633 - $63,500 • Hybrid

About The Position

The Managed Care Oversight Investigator conducts inquiries and investigations into suspected fraud, waste, and abuse within the Medicaid behavioral and physical health provider network. This role supports the integrity of state healthcare expenditures and promotes program compliance. Specifically, this position is responsible for conducting thorough investigations of cases referred by health plans to ensure compliance with managed care regulations, contractual obligations, and program integrity standards. This role involves reviewing referral documentation, analyzing member and provider data, establishing credibility based on submission of potential fraud, waste, or abuse, and collaborating with internal teams and external stakeholders to resolve issues.

Requirements

• Master's degree in a discipline relative to the program from an appropriately accredited institution and two years of related experience; or Bachelor’s degree in a discipline relative to the program area from an appropriately accredited institution and four years of related experience; or an equivalent combination of education and experience.

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.
• Skilled in data collection, analysis, program evaluation, quality assurance, investigative techniques, and conducting audits and documentation reviews.
• Effective communicator with experience explaining policy, delivering training, and collaborating with agencies, providers, and diverse stakeholder groups both orally and in writing.
• Strong organizational skills with the ability to plan, prioritize, and coordinate complex statewide program components, supported by proficiency in Microsoft Office applications.
• 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

• Monitors monthly reports to ensure MCC(s) are in compliance with federal and state contract requirements.
• Position reviews the MCC(s) operations manuals to ensure compliance with all standards related to fraud, waste and abuse.
• Position conducts preliminary reviews of cases sent to Office of Compliance and Program Integrity (OCPI) from MCC(s) for review.
• Attends monthly and quarterly meetings as required with MCC(s) to monitor MCC(s) program integrity activities and discuss findings, share information regarding investigation and audits.
• Provide direct feedback to MCC(s) regarding program integrity functions ensuring federal and state contract requirements, compliance best practices and MCC(s) contract requirements are met.
• Conducts provider investigation activities in accordance with the documented policies and procedures for NC Medicaid’s provider investigations operations.
• Investigate provider billing and service claims for clinical necessity, coding accuracy, Medicaid compliance, and contractual adherence.
• Receives, researches and investigates provider complaints and allegations.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees