About this role
Role Overview
- Support analytical verification and quality aspects involved in care processes, including observation of the entire process within the administrative and contractual scope, ensuring agreement on technical services provided and billing for materials and medications as agreed between payers and providers.
- Perform counter-audits of medical accounts related to in‑person (in loco) audits.
- Follow the account-closing schedule in accordance with the area's monthly planning.
- Analyze and discuss items on hospital bills, inpatient stays, outpatient services and emergency care, with the aim of ensuring payment for services actually provided to patients of contracting payers.
- Analyze, discuss and support appeals against claim denials (glosas) to either authorize payment or uphold the denial.
- Follow technical and operational healthcare standards to ensure appropriate patient care.
- Assist in preparing technical manuals.
- Conduct audit activities and evaluate requested processes and procedures to improve suitability and quality, identifying discrepancies and proposing measures to enhance performance.
- Support technical assessment of the clinical appropriateness of requested procedures and authorize them after review.
- Support technical evaluation of the appropriateness of OPME (orthoses, prostheses and special materials) to select lower-cost options when applicable.
- Support technical evaluation of the appropriateness of oncology-related procedures and medications.
- Review and authorize Home Care requests.
- Manage requests and authorizations within the SLA (Service Level Agreement) that fall under the nurse's responsibility.
- Identify errors, fraud and non-conformities and provide continuous education to minimize them and reduce inconsistencies.
Requirements
- Bachelor's degree in Nursing with active registration at the Regional Nursing Council (COREN).
Benefits
- Meal voucher / food allowance 🥗
- Health insurance / medical plan 🩺
- Life insurance 🥰🏘️
- Dental plan 🦷
- Birthday day off 🎉
- Transportation voucher / transit allowance 🚍
- 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 or MBA programs (after 3 months with the company) 📚
- Marriage assistance (after 1 year)
- Daycare assistance: (Amounts adjusted annually for children up to 60 months)
- Maternity/paternity support: Newborn hospital discharge kit 👩🏽🍼
- TotalPass benefit program 💪🏼