Bring your expertise to the Rising team to assist with the expansion of our new demand package product!
The Lead Legal Nurse plays a critical role in evaluating the medical necessity, appropriateness, and cost of medical services within auto, general liability, and workers’ compensation claims while leading the direction and the program. This role combines clinical expertise with analytical review to support claim adjudication, demand package evaluation, and dispute resolution.
The ideal candidate has some leadership experience or is looking to step up, along with experience reviewing plaintiff demand packages, assessing medical records for causation, necessity, and reasonableness, cost, and supporting defensible positions in negotiation, litigation, or audit environments. and is successfully able to:
- Evaluate liability demand packages, including medical records, billing, and treatment timelines to identify gaps, inconsistencies, and cost drivers
- Utilize evidence-based guidelines (ODG, MCG, InterQual, etc.) to determine authorization versus escalation to Peer or Physician Review
- Review and analyze past and projected cost of medical treatment.
- Document appropriately in Rising’s systems (and client systems as needed), and issue demand package review report
- Write clear, concise, and defensible nurse summaries on all UR and demand review files.
- Establish and maintain collaborative relationships with clients, attorneys, and internal stakeholders
Requirements
- An Associate or Bachelor’s Degree in nursing
- Hold an active RN license in one or more states
- Experience reviewing drafting and/or reviewing liability demand packages or supporting claim litigation/negotiation (strongly preferred)
- Minimum 5 years of clinical, legal, utilization review, or case management experience
- Certifications such as CCMC, CLNC, CMAC, CRRN, CDMS, or COHN (preferred)
- Experience with auto liability, general liability, and/or Workers' Compensation
- The ability to set priorities and work both autonomously and as a team member
- Well-developed time-management, organization, and prioritization skills
- Excellent analytical skills
- Superb oral and written communication
- The ability to gather data, compile information, and prepare summary reports
- Strong interpersonal and conflict resolution skills
- Experience in a fast-paced, multi-faceted environment
- Demonstrated persistence and attention to detail
- General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines
- Working knowledge of: Microsoft Word, Excel, and Outlook
- Ability to remain calm during stressful situations
- A customer-service mindset
Benefits
If you are ready to join a team of professionals dedicated to making a difference and making lives better, please apply today!