Lead Legal Nurse

Rising Medical Solutions•Chicago, IL

About The Position

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.

Requirements

An Associate or Bachelor’s Degree in nursing
Hold an active RN license in one or more states
Minimum 5 years of clinical, legal, utilization review, or case management experience
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

Nice To Haves

Some leadership experience or looking to step up
Experience reviewing plaintiff demand packages, assessing medical records for causation, necessity, and reasonableness, cost, and supporting defensible positions in negotiation, litigation, or audit environments.
Experience reviewing drafting and/or reviewing liability demand packages or supporting claim litigation/negotiation (strongly preferred)
Certifications such as CCMC, CLNC, CMAC, CRRN, CDMS, or COHN (preferred)

Responsibilities

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