The State of North Carolina is a southeastern state with 100 counties and is the ninth most populous state in the U.S. North Carolina's moderate climate, rich c
Program Integrity Coordinator
Location
United States
Posted
4 days ago
Salary
$52.6K - $92.0K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Program Integrity Coordinator
State of North Carolina
Role Description In North Carolina Medicaid, County Departments of Social Services perform the Medicaid program integrity function under the oversight of 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). - 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. - 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, documenting review findings 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). - Responsible for implementing the State PI Compliance Monitoring Plan by conducting monthly compliance reviews. - Conducts collaborative compliance monitoring exit meetings with the county Program Integrity departments. Qualifications - Considerable understanding of social services and Medicaid program areas. - Ability to research, analyze, and interpret Federal and State laws. - Working knowledge of the NCFAST eligibility system. - Proven ability to establish and maintain effective working relationships. - Experience in compliance monitoring and ensuring regulatory adherence. - Strong analytical, oral, and written communication skills. 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. Benefits - Health insurance options. - Standard and supplemental retirement plans. - NCFlex program (numerous high-quality, low-cost benefits on a pre-tax basis). - Paid vacation, sick, and community service leave. - Paid parental leave for eligible employees.
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