Nurse Consultant II

nc; North Carolina; Híbrido; USD 67.000 - 110.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Hybrid work option

Descripción de la vacante

The Nurse Consultant II at North Carolina Department of Health and Human Services leads clinical analysis to develop Medicaid coverage policies, assesses medical necessity and reimbursement issues, and researches policy with regulators and providers. The role collaborates with managed care plans and internal teams for consistent program implementation.

Responsibilities include reviewing complex claims, advising on policy interpretation, and guiding education for providers and stakeholders.

Formación

• Experience researching, analyzing, and interpreting Medicaid policies, regulations, standards, and technical guidance to develop clear, actionable recommendations.
• Documented success developing, reviewing, and maintaining professional documents such as policies, procedures, reports, guidance materials, and stakeholder communications.
• Proven effectiveness communicating complex clinical and policy information through clear written materials and concise verbal explanations tailored to diverse audiences.
• Established experience collaborating with internal and external stakeholders to gather information, build consensus, resolve issues, and support implementation of new processes or initiatives.
• Demonstrated strong organizational and analytical skills, including managing multiple priorities, meeting deadlines, and completing work independently with minimal supervision.

Responsabilidades

• Develop and maintain Medicaid coverage policies through clinical analysis, policy review, and evaluation of reimbursement and medical necessity issues.
• Conduct policy and regulatory research to ensure alignment with state and federal requirements and support implementation of policy updates.
• Review complex claims, coverage requests, and provider inquiries to verify compliance and inform program decisions.
• Collaborate with managed care plans, providers, and internal staff to support policy interpretation and consistent program implementation.
• Evaluate healthcare trends and program performance data to inform policy recommendations and operational improvements.
• Support development of reimbursement methodologies by analyzing clinical and programmatic information relevant to Medicaid services.
• Provide guidance and education to providers and stakeholders to promote understanding of Medicaid policies, requirements, and procedural updates.
• Assist with implementation of coding and program changes by reviewing technical guidance and coordinating with relevant partners.
• Participate in quality assurance activities that strengthen policy accuracy, regulatory compliance, and program operations.
• Address provider concerns through targeted analysis, issue resolution, and development of clear, actionable recommendations.

Conocimientos

Medicaid policy analysis

Policy interpretation

Stakeholder communication

Policy implementation support

Analytical skills

Descripción del empleo

Agency Dept of Health and Human Services Division HEALTH BENEFITS Job Classification Title Nurse Consultant II (NS) Position Number 60042694 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 Nurse Consultant II provides clinical consultation and program support for North Carolina Medicaid by developing and maintaining coverage policies, evaluating reimbursement and medical necessity issues, and conducting policy and regulatory research. The position reviews complex claims, coverage requests, and provider inquiries to ensure compliance with state and federal requirements. It collaborates with managed care plans, providers, fiscal operations, and other stakeholders to support policy interpretation, program implementation, quality assurance activities, and provider education.

This role analyzes healthcare trends, recommends policy improvements, resolves provider concerns, and contributes to reimbursement methodologies and program operations. This position functions within the Medical Health Policy Section of the Division of Health Benefits.

Key Duties Include

• Develop and maintain Medicaid coverage policies through clinical analysis, policy review, and evaluation of reimbursement and medical necessity issues.
• Conduct policy and regulatory research to ensure alignment with state and federal requirements and support implementation of policy updates.
• Review complex claims, coverage requests, and provider inquiries to verify compliance and inform program decisions.
• Collaborate with managed care plans, providers, and internal staff to support policy interpretation and consistent program implementation.
• Evaluate healthcare trends and program performance data to inform policy recommendations and operational improvements.
• Support development of reimbursement methodologies by analyzing clinical and programmatic information relevant to Medicaid services.
• Provide guidance and education to providers and stakeholders to promote understanding of Medicaid policies, requirements, and procedural updates.
• Assist with implementation of coding and program changes by reviewing technical guidance and coordinating with relevant partners.
• Participate in quality assurance activities that strengthen policy accuracy, regulatory compliance, and program operations.
• Address provider concerns through targeted analysis, issue resolution, and development of clear, actionable recommendations.

Knowledge Skills and Abilities/Management Preferences

Salary Grade Range: $66,696.00 - $110,049.00

Recruitment Range: $66,696.00 - $87,715.00

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 researching, analyzing, and interpreting complex Medicaid policies, regulations, standards, and technical guidance to develop clear, actionable recommendations.
• Documented success developing, reviewing, and maintaining professional documents such as policies, procedures, reports, guidance materials, and stakeholder communications.
• Proven effectiveness communicating complex clinical and policy information through clear written materials and concise verbal explanations tailored to diverse audiences.
• Established experience collaborating with internal and external stakeholders to gather information, build consensus, resolve issues, and support implementation of new processes or initiatives.
• Demonstrated strong organizational and analytical skills, including managing multiple priorities, meeting deadlines, and completing work independently with minimal supervision.

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

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, sen