Nurse Consultant II

Dept of Health and Human Services

HEALTH BENEFITS

Nurse Consultant II (NS)

60042694

MH17

The 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.

Tresha Walker