High-Cost Funds Analyst

Description

Job Summary: A professional to conduct administrative audits, analyze claim denials, support treatment authorizations, and manage systems—contributing to healthcare processes. Key Highlights: 1. Conduct administrative audits and analysis of claim denials 2. Support analysis of treatment request and billing submissions 3. Manage and configure the Sys-On system Description: MANDATORY: Ongoing undergraduate degree Knowledge of the Sys\-On system DESIRED: Completed undergraduate degree Knowledge of oncology protocols * Collaborate with Accounts Analysts to perform administrative audits and analyze claim denials for accounts submitted by Member Cooperatives; * Support Authorization Analysts in executing the analysis process for chemotherapy, immunobiological, and radiotherapy treatment requests within the Sys\-On system—including oral medication procurement and billing; * Assist in executing the monthly billing process for Funds; * Populate strategic and operational indicators, action plans, and maintain updated workflows, SOPs, and forms; * Conduct training sessions and meetings with Member Cooperatives and Service Providers to align processes and/or clarify doubts; * Contribute to developing new process management systems and/or improving existing systems; * Develop and update input and negotiated rate tables with FAC Providers; * Manage access rights and permissions to the Sys\-On system; * Register, update, and monitor DUTs (Technical Evaluation Reports) in the Sys\-On system for use in medical opinions. Also monitor ANVISA’s incorporation of new medications or updates to package inserts, registering them in the Sys\-On system to update the drug database and support medical opinions; * Analyze medical audit opinions to identify non-conformities or violations of administrative regulations that may cause losses to Member Cooperatives; * Perform Third-Opinion reviews; * Develop indicator analyses and plans for the Program’s Critical Analysis; * Generate managerial reports on reimbursement payments due to Member Cooperatives and forward them to the Finance Department of Unimed Central RS; * Configure and maintain the SGMED system regarding FAC Provider negotiations; * Close and bill FAC Provider service outputs per period/competency for value reconciliation and submission of payment reports to Member Cooperatives and Providers; * Conduct training and system implementation for new FAC Providers; * Analyze, interpret, and review contracts related to negotiations with new Providers and amendments; * Provide support to Member Cooperatives and Providers using the Sys\-On system and Accounts Management Portal; * Analyze, monitor, and address disputes submitted by FAC Providers via the Sys\-On system or Medical Accounts Portal, recording denial reasons for IDF monitoring; * Ensure compliance with Information Security Policies and LGPD; * Support Authorization Analysts in executing the analysis process for chemotherapy, immunobiological, and radiotherapy treatment requests within the Sys\-On system—including oral medication procurement and billing. 2512100202181911973