Medical Auditor – Pre-Authorization Audit

Role Overview

• Perform audits of procedures by reviewing claim forms, verifying claim eligibility, checking whether materials were quoted, confirming the relevance and currency of the claim form, and comparing the information on the form with the procedure and materials used.
• Conduct audits of Ambulatory Diagnostic and Therapeutic Support Services, analyzing the compatibility of procedures and costs, checking general information, and denying (glosa) procedures when not justified.
• Analyze claim forms in detail, verify item-by-item what was used, compare with the request and procedure, approving authorizations and/or determining denials (glosa).
• Perform continuous review and compliance assessment of records and procedures carried out, comparing them against standards, internal procedures and legislation, taking steps to apply denials (glosa) when appropriate.
• Develop studies, compile information and present indicators to support the management of surgery authorizations, management reports and financial analyses.
• Check requests against ANS deadlines (ANS
• National Agency for Supplementary Health), managing authorization timeframes.
• Execute and audit hospital billing accounts, using tools such as contracts, agreed price tables and mathematical calculations to ensure correct billing.
• Monitor incoming items that are being quoted or not, inspect outgoing items, and analyze and advise the involved departments.
• Verify general information and deny (glosa) procedures when not justified.
• Compile all information related to each requested surgery, generate reports and control the authorization workflow.

Requirements

• Medical degree (MD or equivalent)
• Active registration with the Regional Medical Council (CRM)
• Postgraduate qualification in Health Services Management preferred

Benefits

• Position also open to candidates with disabilities (PwD)