Program Integrity Coordinator

Agency

Dept of Health and Human Services

Division

HEALTH BENEFITS

Job Classification Title

Program Coordinator IV (NS)

Position Number

60042837

Grade

NC14

About Us

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.

Description of Work

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.

Knowledge Skills and Abilities/Management Preferences

Salary Grade Range $52,592 - $92,036

Recruitment Range $52,592 -  $66,675

**Position is 100% remote**

Candidates now meet the minimum qualifications of a position if they meet the minimum education and experience listed on the vacancy announcement.

The Knowledge, Skills, and Abilities (KSAs)/ Management Preferences are not required. Applicants who possess the following skills are preferred:

• 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.

Management Preferences:

• Previous and proven work experience as a Medicaid eligibility caseworker or program integrity investigator.

• Working experience with NCTRACKS.

• Working experience with NCFAST.

Physical Requirements:

Fingering: Picking, pinching, typing or otherwise working, primarily with fingers rather than with the whole hand or arm as in handling.

Posting closes at 11:59 p.m. the night before the closing date

Position is funded in part through federal funds

About the NC Division of Health Benefits:
The Division of Health Benefits (DHB) within NCDHHS is committed to advancing innovative solutions that improve health, promote well-being and foster independence for all North Carolinians. DHB manages and oversees North Carolina Medicaid and other programs that provide access to services and supports for parents, children, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders. With a budget over $27 billion in state and federal funds per fiscal year, DHB ensures that more than 108,000 enrolled providers are reimbursed for delivering covered services to 3.1 million beneficiaries. 

All positions in the Division of Health Benefits are exempt from the State Human Resources Act (G.S. 126) except for the provisions of Articles 6 and 7 per HB 372 Section 20.

Compensation & 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.  

Visit website for State Benefits

Supplemental and Contact Information

The North Carolina Department of Health and Human Services (DHHS) is an Equal Opportunity Employer that embraces an Employment First philosophy, which consists of complying with all federal laws, state laws, and Executive Orders.  We are committed to reviewing requests for reasonable accommodation at any time during the hiring process or while on the job.  For more information about DHHS: https://www.ncdhhs.gov/.

DHHS uses the Merit-Based Recruitment and Selection Plan to fill positions subject to the State Human Resources Act with the most qualified individuals.  Hiring salary will be based on relevant qualifications, internal equity, and budgetary considerations pertinent to the advertised position.

In accordance with the Governor’s Executive Order 303, our agency supports second-chance employment for individuals who were previously incarcerated or justice-involved.  We invite all potential applicants to apply for positions for which they may be qualified.

               

Application Process
Be sure to complete the application in its entirety.   Resumes will not be accepted in lieu of completing this application. 

• Information should be provided in the appropriate areas, to include the following: Education, including high school and all degrees obtained, Work Experience, and Certificates & Licenses. It is critical to our screening and salary determination process that applications contain comprehensive candidate information.

• Answers to Supplemental Questions are not a substitute for providing all relevant information within the body of your application. To receive credit for the supplemental questions, you must provide supporting information within the "Work Experience" section of the application to support your answers.

• If multiple applications are submitted to an individual posting, only the most recent application received prior to the closing date will be accepted. Applications must be submitted by 11:59 PM the night BEFORE the closing date.

• Applicants may be subject to a criminal background check. All candidates selected for positions considered "Positions of Trust" will be subject to a criminal background check.

• Due to the volume of applications received, we are unable to provide information regarding the status of your application over the phone. To check the status of your application, please log in to your account.  Upon the closing date, applications are "Under Review" and will be screened by Human Resources for qualified applicants. The hiring process may take several weeks.

• Degrees must be received from appropriately accredited institutions.  Transcripts and degree evaluations may be uploaded with your application. The State of North Carolina/Office of State Human Resources uses the National Association of Credential Evaluation Services (NACES) as a referral resource for applicants who need to have their credentials certified as equivalent.

• For a list of organizations that perform this specialized service, please visit the NACES membership website at https://www.naces.org/members. 

Degree/College Credit Verification

Degrees must be received from appropriately accredited institutions.  Transcripts, degree evaluations and cover letters may be uploaded with your application.

Veterans’ and National Guard Preference

• Applicants seeking Veteran's Preference must attach a DD-214 Member-4 Form (Certificate of Release or Discharge from Active Duty) to their applications.

• Applicants seeking National Guard Preference must attach an NGB 23A (RPAS), along with the state application, if they are a current member of the NC National Guard in good standing. 

• Applicants who are former members of either the NC Army National Guard or the NC Air National Guard, with honorable discharge and six years of creditable service, must attach a copy of the DD 256 or NGB 22, along with the state application.

ADA Accommodations

Consistent with the Americans with Disabilities Act (ADA) and the Pregnant Workers Fairness Act (PWFA), DHHS is committed to the full inclusion of all qualified individuals. As part of this commitment, DHHS will ensure that people with disabilities, or known limitations covered by the PWFA, are provided with reasonable accommodation.  If reasonable accommodation is needed to participate in the job application or interview process, please contact the person Substance Abuse Professional Practice Board, etc.) indicated below.

CONTACT INFORMATION: 

If there are any questions about this posting, please contact Talent Acquisition at [email protected]. Resumes will not be accepted in lieu of completing this application.

Minimum Education and Experience

Some state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details.

Some state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details.

• 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.

EEO Statement

The State of North Carolina is an Equal Employment Opportunity Employer and dedicated to providing employees with a work environment free from all forms of unlawful employment discrimination, harassment, or retaliation. The state provides reasonable accommodation to employees and applicants with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for religious beliefs, observances, and practices.

Recruiter:

Tandrea Lanae Jones

Email:

[email protected]