Nurse Consultant II

State of North Carolina•Wake County, NC

2d•Hybrid

About The Position

The Nurse Consultant II provides clinical consultation and program support for North Carolina Medicaid within the Medical Health Policy Section of the Division of Health Benefits. The position develops and maintains coverage policies, evaluates reimbursement and medical necessity issues, conducts policy and regulatory research, and reviews complex claims, coverage requests, and provider inquiries for compliance with state and federal requirements. The role works with managed care plans, providers, fiscal operations, internal staff, and other stakeholders to interpret policies, support program implementation, conduct quality assurance, and provide provider education. It analyzes healthcare trends and program data, recommends policy and operational improvements, supports reimbursement methodologies, resolves provider concerns, and helps implement coding and program changes. This position is eligible for a hybrid work option and is funded in part through federal funds. Applicants must provide an RN license on the application.

Requirements

Be licensed to practice as a Registered Nurse in North Carolina.
Have two years of clinical experience in the area of specialization.
Provide an RN license on the application.

Nice To Haves

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

Responsibilities

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 about 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 to strengthen policy accuracy, regulatory compliance, and program operations.
Address provider concerns through targeted analysis, issue resolution, and clear, actionable recommendations.