Nurse Consultant II

State of North Carolina•Wake Forest, NC

22h•$66,696 - $110,049•Hybrid

About The Position

The Nurse Consultant II supports NC Medicaid within the Medical Health Policy unit by developing and revising coverage policies, researching new coverage requests, and reviewing claims to determine medical necessity. The position provides consultation on clinical policies, procedure codes, and reimbursement processes, and supports annual procedure code updates and program implementation activities. The role reviews assigned health plan policies, reports, and deliverables for compliance with program requirements, and collaborates with providers, health plans, financial operations, the fiscal agent, and other agency staff. It also assists with provider education, responds to policy-related inquiries and appeals, and contributes to quality assurance. This is an individual-contributor role requiring sound clinical judgment, effective communication, and the ability to manage multiple policy and program priorities. The position is eligible for a hybrid work option and is funded in part through federal funds. The physical work includes sedentary office work involving computer use, reading and analyzing information, verbal communication, and occasional standing and walking. The role requires an active North Carolina Registered Nurse license and two years of clinical experience in the area of specialization.

Requirements

Licensed to practice as a Registered Nurse in the State of North Carolina.
Two years of clinical experience in the area of specialization.
Provide the RN license with the application.

Nice To Haves

Experience researching, analyzing, and interpreting complex policies, regulations, standards, or technical guidance and developing actionable recommendations to 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.
A proven track record of partnering with internal and external stakeholders to collect information, facilitate discussions, resolve operational issues, and support implementation of process improvements and strategic initiatives.
Documented experience applying organizational, analytical, and project management practices to manage multiple priorities, coordinate concurrent assignments, meet deadlines, and complete work independently while maintaining quality and accuracy.

Responsibilities

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 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.