Nurse Consultant II

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

Agency

Dept of Health and Human Services

Division

HEALTH BENEFITS

Job Classification Title

Nurse Consultant II (NS)

Position Number

65024490

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 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.

The Knowledge, Skills, and Abilities (KSAs)/ Management Preferences are not required. Applicants who possess the following skills are preferred:

• 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.

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

RN License Must Be Provided On Application

Physical Requirements:

• Sedentary office work involving computer use
• Reading and analyzing information
• Verbal communication
• Occasional standing and walking
• See the position description and ADA checklist

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, 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.

Minimum Education and Experience

Some 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 Statement

The 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 Walker

Contact:

DHHS Workday Support Form