Lead Nurse Consultant in Fearrington Village, NC
Job Description
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 North Carolina Medicaid Office of Compliance and Program Integrity (OCPI) monitors the Medicaid community—including beneficiaries, providers, vendors, and internal staff—for 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 OCPI’s 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: $64,211.00 - $105, 949.00
Recruitment Range: $64,211.00 - $81,694.00
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 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 5:00 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 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 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
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
talentacquisition@dhhs.nc.gov
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 North Carolina Medicaid Office of Compliance and Program Integrity (OCPI) monitors the Medicaid community—including beneficiaries, providers, vendors, and internal staff—for 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 OCPI’s 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: $64,211.00 - $105, 949.00
Recruitment Range: $64,211.00 - $81,694.00
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 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 5:00 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 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 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
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
talentacquisition@dhhs.nc.gov
Job Details
Medical Speciality
Public health
Employment Type
Full-time
Required License
RN (Registered Nurse)
Work Setting
Office
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About North Carolina Department of Health and Human Services
The North Carolina Department of Health and Human Services (DHHS) is a governmental organization dedicated to improving the health, safety, and well-being of all North Carolinians. They provide essential services to vulnerable populations such as children, elderly, disabled, and low-income families. DHHS works collaboratively with healthcare professionals, community leaders, and advocacy groups to deliver a wide range of health and human services. The department is organized into 30 divisions and offices focusing on health, human services, administrative, and support functions. DHHS oversees 14 facilities including developmental centers, psychiatric hospitals, and treatment centers. Their mission is to advance innovative solutions that foster independence and promote well-being, with values centered around being people-focused, promoting teamwork, proactive communication, transparency, stewardship, and joy in the workplace.