Join the Rising team where our new 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. This role combines clinical expertise with analytical review to support claim adjudication, demand package evaluation, and dispute resolution.

 The ideal candidate has 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

• Competitive base salary, profit sharing, 401k matching, generous time off, and career growth opportunities
• A relaxed, yet upbeat, work environment
• Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Rising Medical Solutions, Inc Profile (topworkplaces.com)
• We're on YouTube! Check out our culture at: http://www.youtube.com/user/RisingMedical
• Want to see more? Check out our:
• Facebook: https://www.facebook.com/RisingMedicalSolutions
• LinkedIn: http://www.linkedin.com/company/rising-medical-sol...
• Glassdoor: http://www.glassdoor.com/Overview/Working-at-Rising-Medical-Solutions- EI_IE322608.11,35.htm pages

If you are ready to join a team of professionals dedicated to making a difference and making lives better, please apply today!