Retrospective medical billing audit: Perform technical analysis and audit of medical-hospital accounts, ensuring compliance between the care provided, billed items, medical protocols, and contractual agreements.
Regulatory management and ANS: Draft medical opinions and technical responses to Preliminary Intermediation Notifications (NIP) and official letters addressed to the National Supplementary Health Agency (ANS).
Defenses and appeals: Prepare technical responses and defenses to Notices of Infraction directed to the ANS, working in close coordination with legal and regulatory departments.
Continuous improvement: Map care-delivery discrepancies and propose corrective measures to ensure faithful compliance with established standards for the provision of care in the supplementary health sector.

Education: Medical degree with active and regular registration with the Regional Medical Council (CRM).
Company registration (CNPJ): Be part of the company's shareholder structure with full management and legal representation powers, or establish your own legal entity (MEI/individual micro-entrepreneur is not permitted). The CNPJ must include, as a primary or secondary economic activity (CNAE), one of the following codes: 86.50-0-99 or 86.60-7/00.
Specialization: Postgraduate degree or specialization in Medical Audit and/or Legal areas, preferably with emphasis on Supplementary Health.
Solid experience in Retrospective Medical Auditing (analysis of billing/accounts and medical records).
Proven prior experience with medical and hospital billing fee schedules.
Proficiency in CBHPM (Brazilian Hierarchical Classification of Medical Procedures).
Intermediate to advanced knowledge of Microsoft Office.
Prior experience working in health plan operators / healthcare payers.

Medical Auditor, Retrospective

Key skills