About this role
Role Overview
- Support analytical verification and the quality aspects involved in care processes, including observation of the entire administrative and contractual workflow to ensure agreement between the technical service provided and the billing of materials and medications as agreed between payers and providers.
- Perform counter-audits of medical bills related to in‑person (in loco) audits.
- Follow the account-closing schedule according to the department's monthly planning.
- Analyze and discuss items on hospital bills, inpatient admissions, outpatient services and emergency care, aiming to ensure payment for services actually provided to patients of contracting payers.
- Analyze, discuss and support appeals against claim denials in order to either release payment or uphold the denial.
- Adhere to technical and operational healthcare standards to ensure appropriate patient care.
- Assist in the preparation of technical manuals.
- Perform auditing activities and evaluations of requested processes and procedures to improve their suitability and quality, identifying eventual discrepancies and proposing measures to enhance performance.
- Support technical analysis of the clinical appropriateness of requested procedures and authorize them after review.
- Support technical analysis of the appropriateness of OPME (orthoses, prostheses and special medical materials) to minimize costs.
- Support technical analysis of the appropriateness of oncology procedures and medications.
- Review and authorize Home Care requests.
- Manage requests and authorizations under SLA (Service Level Agreement), within the nurse's area of responsibility.
- Identify errors, fraud and nonconformities and provide ongoing education to minimize them and reduce discrepancies.
Requirements
- Bachelor's degree in Nursing and active registration with the Regional Nursing Council (Conselho Regional de Enfermagem / COREN).
Benefits
- Meal allowance / food voucher 🥗
- Health insurance 🩺
- Life insurance 🥰🏘️
- Dental plan 🦷
- Birthday day off 🎉
- Transportation voucher 🚍
- Corporate University: IPED / Allura — free corporate education platform 📚
- Certification incentive: Additional compensation for each certification according to current policy (after 3 months with the company) 📚
- Education assistance: Reimbursement of up to 50% for postgraduate studies or MBA (after 3 months with the company) 📚
- Marriage assistance (after 1 year)
- Childcare assistance (amounts adjusted annually for children up to 60 months)
- Maternity/Paternity package: baby hospital discharge kit 👩🏽🍼
- TotalPass wellness benefits 💪🏼