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. 

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 accepted. Applications must be submitted by 11:59 PM on the closing date. 
• Applicants may be subject to a criminal background check. All candidates selected for positions considered "Positions of Trust" will be subject 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 application. The 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 https://www.naces.org/members . 

Degree/College 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 Veteran's Preference must attach a DD-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 the 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  talentacquisition@dhhs.nc.gov . 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

T he 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:

Tresha Walker

Contact:

DHHS Workday Support Form