Associate Director, Provider Compliance

Dept of Health and Human Services

HEALTH BENEFITS

Human Services Program Manager III (NS)

60042687

NC22

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.

Key Duties Include
• 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.

Lisa M Sasser