Nurse Consultant II

State of North Carolina - Health & Human Services; North Carolina; Hybrid; USD 67,000 - 110,000; Full time

Benefits offered by this job

Hybrid work option

Job summary

State of North Carolina - Health & Human Services is seeking a Nurse Consultant II to provide clinical consultation and policy support for Medicaid coverage rules. The role includes policy development, regulatory research, and collaboration with managed care plans, providers, and internal teams to ensure compliant program operations.

The successful candidate will analyze reimbursement methodologies, educate providers, and contribute to quality assurance activities across the Medicaid program

Qualifications

• RN license and two years of clinical experience in the relevant area.
• Experience researching and interpreting Medicaid policies and guidance.
• Ability to communicate complex clinical information clearly to diverse audiences.
• Ability to work with internal and external stakeholders with minimal supervision.

Responsibilities

• Develop and maintain Medicaid coverage policies through clinical analysis and policy review.
• Research policy and regulatory guidance to support implementation of updates.
• Review complex claims, coverage requests, and provider inquiries for compliance.
• Collaborate with managed care plans, providers, and staff to implement policies.
• Evaluate healthcare trends to inform policy recommendations and operations.

Skills

Policy analysis

Policy communication

Stakeholder collaboration

Organizational skills

Education

Registered Nurse license

Tools

Medicaid claims systems

Job description

AgencyDept of Health and Human ServicesDivisionHEALTH BENEFITSJob Classification TitleNurse Consultant II (NS)Position Number60042694GradeMH17About UsThe 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 WorkThe 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 PreferencesSalary Grade Range: $66,696.00 - $110,049.00Recruitment Range: $66,696.00 - $87,715.00Candidates 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 DateThis Position Is Funded In Part Through Federal FundsThis Position Is Eligible For A Hybrid Work OptionEHRA: 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 7RN License Must Be Provided On The ApplicationAbout 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, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders. With a budget over $27 billion in state and federal funds per fiscal year, DHB ensures that more than 108,000 enrolled providers are reimbursed for delivering covered services to 3.1 million beneficiaries.All positions in the Division of Health Benefits are exempt from the State Human Resources Act (G.S. 126) except for the provisions of Articles 6 and 7 per HB 372 Section 20.Compensation and Benefits:The State of North Carolina offers excellent comprehensive benefits. Employees can participate in health insurance options, standard and supplemental retirement plans, and the NCFlex program (numerous high-quality, low-cost benefits on a pre-tax basis). Employees also receive paid vacation, sick, and community service leave. In addition, paid parental leave is available to eligible employees.Visit the website for State Benefits .Supplemental Contact Information:The North Carolina Department of Health and Human Services (DHHS) is an Equal Opportunity Employer that embraces an Employment First philosophy, which consists of complying with all federal laws, state laws, and Executive Orders. We are committed to reviewing requests for reasonable accommodation at any time during the hiring process or while on the job. For more information about DHHS: https://www.ncdhhs.gov/ .DHHS uses the Merit-Based Recruitment and Selection Plan to fill positions subject to the State Human Resources Act with the most qualified individuals. Hiring salary will be based on relevant qualifications, internal equity, and budgetary considerations pertinent to the advertised position.In accordance with the Governor’s Executive Order 303 , our agency supports second-chance employment for individuals who were previously incarcerated or justice-involved. We invite all potential applicants to apply for positions for which they may be qualified.Application ProcessBe sure to complete the application in its entirety. Resumes will not be accepted in lieu of completing this application.Information should be provided in the appropriate areas, to include the following: Education, including high school and all degrees obtained, Work Experience, and Certificates & Licenses. It is critical to our screening and salary determination process that applications contain comprehensive candidate information.Answers to Supplemental Questions are not a substitute for providing all relevant information within the body of your application. To receive credit for the supplemental questions, you must provide supporting information within the \"Work Experience\" section of the application to support your answers.If multiple applications are submitted to an individual posting, only the most recent application received prior to the closing date will be accepted. Applications must be submitted by 11:59 PM on the closing date.Applicants may be subject to a criminal background check. All candidates selected for positions considered \"Positions of Trust\" will be subject to a criminal background check.Due to the volume of applications received, we are unable to provide information regarding the status of your application over the phone. To check the status of your application, please log in to your account. Upon the closing date, applications are \"Under Review\" and will be screened by Human Resources for qualified applicants. The hiring process may take several weeks.Degrees must be received from appropriately accredited institutions. Transcripts and degree evaluations may be uploaded with your application. The State of North Carolina/Office of State Human Resources uses the National Association of Credential Evaluation Services (NACES) as a referral resource for applicants who need to have their credentials certified as equivalent.For a list of organizations that perform this specialized service, please visit the NACES membership website at https://www.naces.org/members .Degree/College Credit VerificationDegrees must be received from appropriately accredited institutions. Transcripts, degree evaluations, and cover letters may be uploaded with your application.Veterans’ and National Guard PreferenceApplicants seeking Veteran's Preference must attach a DD-214 Member-4 Form (Certificate of Release or Discharge from Active Duty) to their applications.Applicants seeking National Guard Preference must attach an NGB 23A (RPAS), along with the state application, if they are a current member of the NC National Guard in good standing.Applicants who are former members of either the NC Army National Guard or the NC Air National Guard, with honorable discharge and six years of creditable service, must attach a copy of the DD 256 or NGB 22, along with the state application.ADA AccommodationsConsistent with the Americans with Disabilities Act (ADA) and the Pregnant Workers Fairness Act (PWFA), DHHS is committed to the full inclusion of all qualified individuals. As part of this commitment, DHHS will ensure that people with disabilities, or known limitations covered by the PWFA, are provided with reasonable accommodation. If reasonable accommodation is needed to participate in the job application or interview process, please contact the person indicated below.CONTACT INFORMATIONIf there are any questions about this posting, please contact Talent Acquisition at [e-mail] . Resumes will not be accepted in lieu of completing this application.Minimum Education and ExperienceSome state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details.Licensed to practice as a Registered Nurse in the State of North Carolina and two years of clinical experience in the area of specialization.EEO StatementT he State of North Carolina is an Equal Employment Opportunity Employer and dedicated to providing employees with a work environment free from all forms of unlawful employment discrimination, harassment, or retaliation. The state provides reasonable accommodation to employees and applicants with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for religious beliefs, observances, and practices.Recruiter:Tresha WalkerContact:DHHS Workday Support Form