High-Cost Funds Analyst (FAC)

Description

Job Summary: Administrative and technical support professional responsible for auditing, account analysis, system management, and oncology process support. Key Highlights: 1. Administrative audit and claim denial analysis 2. Support for chemotherapy, immunobiological, and radiotherapy processes 3. System Sys-On management and configuration Description: REQUIRED: Ongoing undergraduate degree Proficiency in the Sys-On system DESIRED: Completed undergraduate degree Knowledge of oncology protocols * Collaborate with Account Analysts to conduct administrative audits and analyze claim denials on accounts submitted by Member Cooperatives; * Support Authorization Analysts in processing chemotherapy, immunobiological, and radiotherapy treatment requests within the Sys-On system, including oral medication procurement and billing; * Assist in monthly Fund billing processes; * Maintain strategic and operational indicators, action plans, workflows, SOPs, and forms up to date; * Conduct training sessions and meetings with Member Cooperatives and FAC Providers to align processes and/or clarify doubts; * Contribute to developing new process management systems and/or improving existing ones; * Develop and update input and negotiated rate tables with FAC Providers; * Manage user access and permissions within the Sys-On system; * Register, update, and monitor DUTs (Technical Medical Reports) in the Sys-On system for use in medical opinions. Also monitor ANVISA’s incorporation of new medications or updates to drug leaflets, 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 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 FAC Providers and amendments; * Provide support to Member Cooperatives and FAC Providers using the Sys-On system and Accounts Management Portal; * Analyze, monitor, and resolve 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 processing chemotherapy, immunobiological, and radiotherapy treatment requests within the Sys-On system, including oral medication procurement and billing. 2512100202181911973