Medicaid Policy Nurse Consultant II

State of North Carolina; Arkansas; Hybrid; USD 67,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

The North Carolina Department of Health and Human Services (DHHS) seeks a Nurse Consultant II to support NC Medicaid by developing and revising coverage policies, researching requests, and reviewing claims for medical necessity. You will provide clinical policy consultation and assist with program updates while aligning with agency standards.

The role emphasizes collaboration with providers, health plans, and fiscal operations, requiring sound clinical judgment and strong communication across

Qualifications

• Licensed RN in NC with two years of clinical experience in relevant areas.
• Experience researching and interpreting complex policies.
• Ability to communicate with diverse stakeholders.

Responsibilities

• Develop and revise Medicaid coverage policies through clinical review and research.
• Evaluate new coverage requests with supporting clinical and regulatory information.
• Review medical claims to determine medical necessity and coding issues.
• Consult on clinical policy, codes, and reimbursement with internal and external stakeholders.
• Support CPT/ICD-10 code updates and program implementation.
• Collaborate with providers, health plans, and fiscal agents to implement changes.
• Assist with policy-related inquiries and appeals.
• Contribute to quality assurance by reviewing processes and documentation.

Skills

Policy analysis

Stakeholder collaboration

Policy development

Communication skills

Project management

Education

RN license in NC

Job description

The North Carolina Department of Health and Human Services (DHHS) seeks a Nurse Consultant II to support NC Medicaid by developing and revising coverage policies, researching requests, and reviewing claims for medical necessity. You will provide clinical policy consultation and assist with program updates while aligning with agency standards.

The role emphasizes collaboration with providers, health plans, and fiscal operations, requiring sound clinical judgment and strong communication across