Medical Review Clinical Appeals Auditor

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November 13

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BASF

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Chemicals • Agriculture • Healthcare

BASF is a global chemical company that operates across multiple sectors, providing a wide range of products and solutions. The company is focused on innovation and sustainability, serving industries such as agriculture, automotive, construction, electronics, energy, and healthcare. With a commitment to research and development, BASF aims to create chemicals that enhance the quality of life and support sustainable practices worldwide.

10,000+ employees

Founded 1865

🌾 Agriculture

📋 Description

• Responsible for conducting Appeals reviews of new evidence presented by auditee’s • disputing all or part of the findings from medical review audit work completed by the medical review clinical audit team members • communicates and supports the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools • May perform primary audit activity as assigned by management • Performs clinical reviews on medical records to maintain subject matter expertise, and additionally as needed to support business needs • Objectively and accurately documents Appeals results in accordance with department quality policies and procedures, scoring and reporting all Appeals results and routes the result appropriately within audit platform based upon how the Appeal review resulted in a full or partial upholding of the audit finding or with a full or partial overturn • Reviews audit documentation and conducts research, analyzes claims data • Participate in applicable department meetings • Proactively contributes to continuous improvement of activities and sets positive example

🎯 Requirements

• Active unrestricted RN license in good standing • diversified nursing experience providing direct care in an inpatient, skilled nursing or outpatient setting • One or more years of experience in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies and/or medical billing experience for an Insurance Company or hospital or other appropriate medical provider required • 5+ years relevant experience in a provider or payer environment demonstrating breadth and depth of auditing knowledge/skills for the position • Prior experience taking party status in ALJ hearings a plus • Prior experience in role with responsibility for conducting primary audit, utilization management or prior-authorization work, or review of audit work performed by others (QA function, appeals function, lead, supervisory role, etc.) • Prior experience in payer edit development and/or reimbursement policy a plus • Prior experience working in remote setting preferred

🏖️ Benefits

• medical, dental, vision, disability coverage options • life insurance coverage • 401(k) savings plans • paid family/parental leave • 11 paid holidays per year • sick time • vacation time off annually