Associate Director, Provider Compliance

Title: Associate Director, Provider Compliance

Location: Wake County United States

Ful time

Hybrid

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

The NC Medicaid Office of Compliance and Program Integrity (OCPI) monitors the Medicaid community (beneficiaries, providers, vendors and internal staff) for compliance with state and federal regulations and potential fraud, abuse and neglect. OCPI verifies dollars are paid appropriately for covered services by using claim reviews and investigations, implementing recoveries, pursuing recoupments and aggressively identifying other opportunities for cost avoidance.

The Associate Director, Provider Compliance is a senior management position responsible for assisting the Deputy Director/Chief Compliance Officer in key activities of DHB's Office of Compliance and Program Integrity unit. This position will be responsible for establishing and executing effective oversight protocols of the Special Investigations Units of the State's contracted health plans while developing and implementing procedures for conducting provider audits and investigations in accordance with all federal and state rules and regulations to reduce provider fraud, waste and abuse. This position will ensure NC Medicaid managed care organizations have and follow sound principles and practices for conducting provider audits, investigations and monitoring. This role will work in partnership with DHB Provider Operations and DHB Clinical Policy to facilitate the adequate implementation of provider policies and practices which lead to compliance with Centers for Medicare & Medicaid Services (CMS) rules and guidelines and North Carolina legislative requirements for Medicaid providers.

Job Specific Responsibilities:

• Lead the development, maintenance and execution of documented policies and procedures for the establishment of OCPI's provider audits and investigations protocol to prevent illegal, unethical, or improper payment of Medicaid dollars.
• Lead the development, maintenance and execution of documented policies and procedures for NC Medicaid's approach to effective oversight and monitoring of the State's contracted Managed Care Plans' Special Investigations Units.
• Oversee the scope of work development and execution of vendors conducting provider audits and investigations under OCPI responsibility and liaise with other business unit leaders for joint provider audit and investigations efforts.
• Enforce provider policies and procedures to include the use of standardized investigations and corrective actions to address identified and reported violations.
• Ensure that the processes and procedures are aligned with authorized enforcement authorities.
• Develop and perform and/or authorize periodic provider audit initiatives to ensure that compliance with clinical and payment policies is being achieved and that the compliance program is relevant and up to date with the needs and requirements of DHB and CMS.
• Successfully liaise and collaborate with OCPI Compliance Analytics, Medicaid Investigations Division (MID), legal counsel (e.g., DHB Attorney, etc.) and others as necessary for expert consultation, clarification and/or approval of provider compliance-based initiatives and interests, to include escalation of high-priority concerns or violations and prosecutions.
• Measure and report on operational performance and lead the development of plans to improve relevant key performance indicators within the Provider Compliance unit.
• Engage in personnel administration to include but not limited to recruiting, selecting, and managing employees; delegating to staff members; encouraging and fostering professional development; establishing effective professional goals and work plan objectives.

Knowledge Skills and Abilities/Management Preferences

Recruitment Range $100,641 - $107,816

Position is eligible for a hybrid-teleworking schedule to include weekly onsite work hours

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:

• Deep expertise in detecting and preventing fraud, waste, and abuse (FWA) within Medicaid and managed care, supported by the ability to translate data insights into actionable investigative strategies.

• Proven ability to lead complex investigations, analyze evidence, prepare cases for referral, and support criminal or civil proceedings while ensuring compliance with state and federal regulations.

• Demonstrated leadership experience managing large teams, overseeing vendor relationships, and fostering collaboration across internal and external stakeholders.

• Skilled in building and maintaining effective partnerships with law enforcement, prosecutorial agencies, providers, and health plans, supported by exceptional written and verbal communication for reports, presentations, and negotiations.

• Strong proficiency in Microsoft Office applications (Teams, Outlook, Excel, Word) with the ability to coach staff, manage performance, and coordinate high‑impact investigative and program activities.

Management Preferences:

• Previous work experience with a Medicaid agency.

• Experience effectively managing personnel in the execution of provider audits and investigations.

• Considerable knowledge of healthcare operations.

• Familiarity with state of NC contracting processes, including vendor monitoring.

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.

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.