Public Consulting Group LLC (PCG) is a leading public sector solutions implementation and operations improvement firm that partners with health, education, and human services agencies to improve lives. Founded in 1986, PCG employs approximately 2,000 professionals throughout the U.S.—all committed to delivering solutions that change lives for the better. The firm is a member of a family of companies with experience in all 50 states, and clients in three Canadian provinces and Europe. PCG offers clients a multidisciplinary approach to meet challenges, pursue opportunities, and serve constituents across the public sector. To learn more, visit www.publicconsultinggroup.com.

Duties and Responsibilities

Investigate complaints, initiatives and data packages against North Carolina (NC) Medicaid providers and conduct desk and routine reviews of assigned providers to determine compliance with clinical policies, licensing rules, state and federal regulations.Conduct thorough investigations of all complaints and routine reviews including an analysis of all relevant medical, training, credentialing and billing records. When necessary, conduct interviews with individuals who may have relevant information, document all investigative activities, including discovery of all elements of the incident in the case tracking management system.Prepare case mailings, i.e. record request letters, tentative notice of decision letters, appeal summaries, etc. using standard templates.  Communicate with NC Medicaid providers to obtain documentation, provide education as needed, and to address and attend reconsideration appeals as necessary.Create a thorough written report to document the results of the investigations and to recommend corrective actions to the NC Division of Health Benefit (DHB) Office of Compliance and Program Integrity (OCPI). Create written referrals when appropriate to the State Board of Dental Examiners, or other entity as determined through document review and discussion with DHB OCPI.Gather information to write and submit referrals to NC DHB Office of Compliance and Program Integrity for egregious provider behavior.Review and approve provider Corrective Action Plans.Provide weekly status updates to supervisor of all open cases and cases under appeal.Act as mentor to new or less experienced investigators.Other duties as required by project.

Required Skills

Demonstrate ability to think critically, incorporating multiple factors into larger conceptsStrong organizational skills with abilities to simultaneously manage multiple (10 to 20) investigations.Demonstrate ability to work with and relate to others with customer relation techniques, professionalism and with respect for other culturesDemonstrate effective active listening and interviewing skillsStrong computer skills with competence in MS Word, Excel, Outlook and Teams. Demonstrate strong ability to use templates and spreadsheets to document case review findings.Demonstrate ability to foster teamwork with all levels of management and staffDemonstrate ability to work well independently and within a teamSuperior verbal and written communication skillsStrong and independent decision-making skills, with accuracy and attention to detail.

Qualifications

Licensed registered nurse (RN), a licensed social worker (LSW, LISW), or a licensed professional counselor (LPC, LPCC), Dental Hygiene License (RDH)- Current unrestricted license in North Carolina5+ years paid experience in dental health.Prefer at least 2 years’ experience in Medicaid billing, Medicaid programs, incident investigation, quality assurance, and/or clinical risk management

Working Conditions

Office or Remote Setting-occasional travel to Raleigh office

The above is intended to describe the general contents and requirements of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive statement of all duties, responsibilities or skills of personnel so classified.

Compensation:

Compensation for roles at Public Consulting Group varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience.  As required by applicable law, PCG provides the following reasonable range of compensation for this role below. In addition, PCG provides a range of benefits for this role, including medical and dental care benefits, 401k, PTO, parental leave, bereavement leave.

Range: $53,500-$94,800

EEO Statement:

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.