Medicaid Policy Nurse Consultant

State of North Carolina; Wake Forest (NC); Hybrid; USD 67,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

The Nurse Consultant II role at the State of North Carolina DHHS Health Benefits division focuses on developing and revising Medicaid coverage policies, researching coverage requests, and reviewing claims for medical necessity. You will consult on clinical policy, procedure codes, and reimbursement while supporting annual code updates and program implementation activities.

The position requires RN licensure with two years of clinical experience, strong policy analysis skills, and the ability to

Qualifications

• Licensed Registered Nurse with two years of clinical experience in relevant area.
• Experience researching, analyzing, and interpreting complex policies and regulations to support program operations.
• Ability to communicate clearly with diverse stakeholders including leadership, providers, and public audiences.
• Experience coordinating multiple priorities and managing projects with minimum supervision.

Responsibilities

• Develop and revise Medicaid coverage policies through clinical review and research.
• Review medical claims to determine medical necessity and identify coding/reimbursement issues.
• Provide consultation on clinical policy, codes, and reimbursement requirements for internal and external stakeholders.
• Support CPT/ICD-10 code updates and impact analysis for policy changes.
• Collaborate with providers, health plans, and agency teams to implement policy and claims processing changes.

Skills

Policy analysis

Policy development

Stakeholder communication

Project management

Research and evaluation

Education

RN licensure

Job description

The Nurse Consultant II role at the State of North Carolina DHHS Health Benefits division focuses on developing and revising Medicaid coverage policies, researching coverage requests, and reviewing claims for medical necessity. You will consult on clinical policy, procedure codes, and reimbursement while supporting annual code updates and program implementation activities.

The position requires RN licensure with two years of clinical experience, strong policy analysis skills, and the ability to