Clinical Investigator II

Agency
Dept of Health and Human Services
Division
HEALTH BENEFITS
Job Classification Title
Nurse Consultant II (NS)
Position Number
60042874
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 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 Clinical Investigator II supports the Office of Compliance and Program Integrity (OCPI) by conducting investigations of Medicaid claims, encounters, payment data, financial information, and medical record documentation to ensure compliance with state and federal regulations.
This position verifies that Medicaid dollars are paid appropriately by applying Medicaid coverage policies, reimbursement rules, participation agreements, and contractual requirements to investigative findings. It performs professional investigative work to detect, investigate, and report potential fraud, abuse, and overutilization involving Medicaid and Health Choice providers and beneficiaries.
The Clinical Investigator II also serves as the primary facilitator for federally required Recovery Audit Contractor (RAC) activities, ensuring proper evaluation of proposed concepts and audit findings. This position contributes to OCPI’s mission of ensuring efficiency, accountability, and appropriate use of Medicaid funds.
Key Duties Include:
– Conduct investigations of Medicaid claims, encounters, financial records, and medical documentation to assess compliance, efficiency, and accountability.
– Apply Medicaid coverage policies, State and Federal regulations, reimbursement methodologies, and payment rules when evaluating investigative findings.
– Review proposed Recovery Audit Contractor (RAC) concepts against clinical coverage policies, reimbursement methodologies, and adjudication rules to recommend disposition prior to audit initiation.
– Validate completed RAC findings by comparing vendor outputs against approved concepts, documented policies, and applicable payment rules.
– Manage secure file transfer exchanges for Medicaid, RAC vendors, and the fiscal agent, including resolution of technical file‑related errors.
– Conduct provider investigation activities according to NC Medicaid’s documented provider investigation procedures.
– Compile and analyze information and statistics from various documentation sources to support investigative conclusions.
– Prepare written summary reports that document findings, conclusions, and recommended dispositions for investigative cases.
– Identify potential fraud, abuse, and overutilization patterns by reviewing investigative data and reporting concerns appropriately.
– Support OCPI’s cost‑avoidance and risk‑management efforts by implementing recoveries, pursuing recoupments, and identifying opportunities for improved payment integrity.
Knowledge Skills and Abilities/Management Preferences
Salary Grade Range: $66,696.00 - $110,049.00
Recruitment Range: $66,696.00 - $81,694.00
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:
Demonstrated experience applying the investigative process to detect, analyze, and document Medicaid fraud, abuse, overutilization, and related compliance issues.
Experience reviewing and interpreting medical, dental, and behavioral health terminology, disease processes, diagnostic procedures, and treatments at an intermediate or higher proficiency level to support clinical investigations.
Proven experience evaluating medical records, medical codes, and claims processing rules to determine compliance with Medicaid coverage policies, reimbursement methodologies, and adjudication standards.
Track record of applying state and federal standards, certifying and accrediting body requirements, and quality assurance principles to assess program integrity and support investigative decisions.
Documented experience training and coaching team members by evaluating work accuracy, providing constructive feedback, and explaining investigative or policy‑related procedures clearly.
The Posting Will Close At 11:59 P.M. The Night Before The End Date
This Position Is Funded In Part Through Federal Funds
This Position Is Eligible For A Hybrid Work Option
EHRA: Per G.S. 126-5(c1) (37), This Position Is EXEMPT From All Provisions Of NC General Statute Chapter 126 (State Human Resources Act) With The Exception Of Articles 6 And 7
RN License Must Be Provided On The Application
Physical Requirements:
Standing
Walking
Fingering
Talking
Hearing
Repetitive movements.
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 and 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 the website for State Benefits.
Supplemental 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.