Lead Nurse Consultant

Agency

Dept of Health and Human Services

Division

HEALTH BENEFITS

Job Classification Title

Nurse Consultant II (NS)

Position Number

Grade

MH17

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 17000 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 North Carolina Medicaid Office of Compliance and Program Integrity (OCPI) monitors the Medicaid communityincluding beneficiaries providers vendors and internal stafffor 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.

Key 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 OCPIs 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.

Knowledge Skills and Abilities/Management Preferences

Salary Range: $64211.00 - $105 949.00

Recruitment Range: $64211.00 - $81694.00

Position is funded in part through federal funds.

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

The posting will close at 11:59 p.m. the night before the end date

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

The following Management Preferences are not required but applicants that possess these skills are preferred:

• 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.

Supplemental Contact Information:

The North Carolina Department of Health and Human Services (DHHS) is an Equal Opportunity Employerthat embraces an Employment First philosophy which consists of complying with all federallaws 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: 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 Governors 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 must be submitted by 5:00 PM on the closing date.

• Applicantsmaybe subject to a criminal background check. All candidates selected for positions considered Positions of Trustwill besubject 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 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 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 Veterans Preference must attach aDD-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 their 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 indicated below.

  CONTACT INFORMATION:

  If there are any questions about this posting please contact Talent Acquisition at. 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.

  Licensed to practice as a Registered Nurse in the State of North Carolina and two years of clinical experience in the area of specialization.

  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:

  LaWanna Baker

  Email: