Nurse Consultant II

Dept of Health and Human Services

HEALTH BENEFITS

Nurse Consultant II (NS)

65024490

MH17

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.

Tresha Walker