Nurse Consultant II

Adult Correction; North Carolina; Hybrid; USD 67,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

The Nurse Consultant II role supports NC Medicaid by developing and revising coverage policies, researching new coverage requests, and reviewing claims to determine medical necessity within the Medical Health Policy unit.

The position collaborates with providers, health plans, and agency teams to implement policy and claims processing changes, while requiring sound clinical judgment and effective communication in a hybrid work environment.

Qualifications

• Experience researching, analyzing, and interpreting complex policies, regulations, standards, or technical guidance and developing actionable recommendations that support program operations, compliance activities, or organizational initiatives.
• Proficiency in developing and maintaining policies, procedures, reports, guidance materials, and stakeholder communications for consistent program implementation.

Responsibilities

• Develop and revise Medicaid coverage policies through clinical review, research, and statewide needs assessment.
• Research new coverage requests and evaluate clinical and regulatory information to inform policy decisions.
• Review medical claims and documentation to determine medical necessity and identify reimbursement or coding issues.
• Provide consultation on clinical policy, procedure codes, and reimbursement requirements for internal and external stakeholders.
• Support annual CPT and ICD-10 code updates by assessing impacts on coverage and claims processing.
• Review managed care plan policies and performance reports to verify compliance with Medicaid standards.
• Collaborate with providers, health plans, financial operations, and other agency teams to implement policy and claims processing changes.
• Analyze coverage issues and develop recommendations to address coding, payment, or medical necessity concerns.
• Support provider education by responding to inquiries and assisting with appeals.
• Contribute to quality assurance by reviewing processes and documentation for accuracy and compliance.

Skills

Clinical policy analysis

Policy development

Stakeholder communication

Project management

Job description

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 supports NC Medicaid by developing and revising coverage policies, researching new coverage requests, and reviewing claims to determine medical necessity within the Medical Health Policy unit. The position provides consultation on clinical policies, procedure codes, and reimbursement processes while supporting annual procedure code updates and program implementation activities. It reviews assigned health plan policies, reports, and deliverables to ensure compliance with program requirements and collaborates with providers, health plans, financial operations, the fiscal agent, and other agency staff.

The role assists with provider education, responds to policy-related inquiries and appeals, and contributes to quality assurance activities. This position operates as an individual contributor and requires sound clinical judgment, effective communication, and the capacity to manage multiple policy and program priorities.

Key Duties Include:

• Develop and revise Medicaid coverage policies through clinical review, research, and assessment of statewide program needs.
• Research new coverage requests and evaluate supporting clinical and regulatory information to inform policy decisions.
• Review medical claims and documentation to determine medical necessity and identify reimbursement or coding issues.
• Provide consultation on clinical policy, procedure codes, and reimbursement requirements for internal and external stakeholders.
• Support annual CPT and ICD‑10 code updates by assessing impacts on coverage, reimbursement, and claims processing.
• Review managed care plan policies, performance reports, and deliverables to verify compliance with Medicaid program standards.
• Collaborate with providers, health plans, financial operations, the fiscal agent, and other agency teams to implement policy and claims processing changes.
• Analyze coverage issues and develop recommendations to address coding, payment, or medical necessity concerns.
• Support provider education efforts by responding to inquiries, clarifying policy requirements, and assisting with appeals.
• Contribute to quality assurance activities by reviewing processes and documentation to ensure accuracy and compliance.

Knowledge Skills and Abilities/Management Preferences

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

Recruitment Range: $66,696.00 - $92,373.00

Candidates now meet the minimum qualifications of a position if they meet the minimum education and experience listed on the vacancy announcement.

Experience researching, analyzing, and interpreting complex policies, regulations, standards, or technical guidance and developing actionable recommendations that support program operations, compliance activities, or organizational initiatives.

Demonstrated success developing, reviewing, and maintaining policies, procedures, reports, guidance materials, and stakeholder communications to support consistent implementation of program and operational requirements.

Proficiency developing and delivering clear, concise written and verbal communications to diverse stakeholder groups, including leadership, partners, providers, and public audiences, to support informed decision-making and program objectives.

Proven track record of partnering with internal and external stakeholders to collect information, facilitate discussions, resolve operational issues, and support successful implementation of process improvements and strategic initiatives.

Documented experience applying organizational, analytical, and project management practices to manage multiple priorities, coordinate concurrent assignments, meet established deadlines, and complete work products independently while maintaining quality and accuracy standards.

Additional Information

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 Application

Physical Requirements: Sedentary office work in