Program Integrity Coordinator

State of North Carolina•1915 Health Services Way Wake, NC

2d•$52,592 - $92,036•Remote

About The Position

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.

Requirements

Bachelor’s degree from an appropriately accredited institution and three (3) years of experience in the program related to the area of assignment; or an equivalent combination of education and experience.

Nice To Haves

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

Responsibilities

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).
Conducts compliance monitoring of County DSS Fraud Plans via on-site monthly visits.
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.
Implements the Centers for Medicare and Medicaid Services (CMS) fraud, waste, and abuse initiatives.
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.
Verifies eligibility factors for members through contacts with businesses, federal and state agencies, and individuals with knowledge specific to the member.
Reviews county performance reports and conducts follow-up with appropriate county staff.
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.
Participates in work groups to create uniformity and standardization on specific processes and formats for all Health Plan Special Investigative Units (SIU).
Implements the State PI Compliance Monitoring Plan by conducting monthly compliance reviews based on the plan scope.
Conducts collaborative compliance monitoring exit meetings with the county Program Integrity departments based on the Compliance Monitoring Plan scope.