Nurse - Auditor - Authorized Audit

Description

Job Summary: A nursing professional responsible for authorized audit of authorization forms, analysis of medical requests, and monitoring of processes to ensure quality and sustainability of resources. Key Highlights: 1. Performing authorized audit and clinical relevance analysis. 2. Focusing on quality and sustainable application of healthcare resources. 3. Opportunity to promote health with respect, cooperation, and innovation. Unimed Goiânia is a medical cooperative founded in 1978, inspired by cooperative principles and the appreciation of medical professionals. As part of the National Unimed System, it has been providing humane, ethical, and high-quality healthcare assistance for over 47 years. With over 2\.900 affiliated physicians, Unimed Goiânia reaffirms its commitment to social medicine, responsibility toward the community, and excellence in caring for people—promoting health with respect, cooperation, and innovation. There’s always a new opportunity to demonstrate your unique approach to caring for everyone! **\#THISISTHEPLAN** **Responsibilities and Duties** **Summary Description:** Conduct authorized audits on authorization forms displayed on screen, analyzing audit rules, Utilization Guidelines (DUT), clinical indication, and medical request relevance; forward forms to specialty audit or Medical Board for denial evaluation if no discrepancies are identified; approve and finalize forms; monitor the entire Medical Board process; contact the attending physician to discuss possible discrepancies; perform medical evaluations; perform medical evaluations; request operational and concurrent audits when necessary; request and analyze supporting documentation, reports, and/or medical opinions; conduct preliminary contractual analysis; identify system alert messages; implement hospital discharge procedures focusing on reducing claims frequency and cost; conduct audits focused on quality and cost-effective resource utilization; apply resources sustainably; assist in conducting technical and cost studies and opinions regarding materials and medications; assist in reviewing Unimed Goiânia’s materials and medications list; advise management on questions arising from authorizations, quantities, and approved values; attend to material and medication suppliers; code high-cost materials and/or medications; assist in developing kits, packages, and/or work protocols; generate and analyze reports and indicators. **Detailed Description:** "Access the audit system \- AUTSC, consult authorization forms assigned according to your audit level and/or specialty; Monitor and track communication channels to take appropriate actions, such as: SGU \- Interactive Chat, GPU, Interface, E\-mails, Teams, Corporate WhatsApp; Analyze clinical indication and coding compatibility of requested services/products against clinical indication and CID codes provided (if any), comparing requested services with clinical indication, CID, examination reports, and medical records; Analyze Utilization Guidelines (DUT) and contractual coverage for procedures, using the WEB tool (SGU AUT SC) to evaluate requests, ensuring authorization occurs appropriately within deadlines established by ANS; Advise management, department heads, and/or coordinators on high-cost medication studies related to presentation, indication, quantity, and value; Advise and substitute immediate leadership upon request; Attend to various administrative needs of the department as designated by coordination, including relocation between work units when required; Address, resolve, and clarify diverse demands related to the Medical Board process; Observe interexchange rules, applying audits based on interexchange regulations; Assist medical auditors in clarifying diverse administrative process questions; Assist in developing protocols and work instructions; Assist less experienced staff in clarifying questions; Assist in monitoring the effectiveness of conducted Medical Boards, analyzing indicators to verify whether requests were resubmitted after Medical Board decisions; Contact individuals involved in the Medical Board process—both local and interexchange—as needed to expedite authorization process completion; Correct and re-evaluate coding processes for both local and interexchange beneficiaries; Create kits, protocols, and/or packages of materials and/or medications for procedure composition; Provide assessment and finalize authorization forms in the system; Direct forms to the pending folder when clinical indication diverges from the requested service/product and/or supporting documents are missing; Draft, receive, and send documents, declarations, internal notices, and various correspondence to respective departments; Forward forms to specialty physician auditors for evaluation whenever denial, Medical Board, and/or Operational Audit is indicated; Monitor the platform (software) used for conducting Medical Boards; Assemble the entire Medical Board process, contacting involved parties to ensure regulatory deadlines are met; Perform other duties relevant to the position, as directed by the area manager." **Requirements and Qualifications** **Job ID: 11167888 Nurse Auditor – Authorized Audit** ******TEMPORARY CONTRACT FOR 6 MONTHS** **Required Qualifications:** * Bachelor’s degree in Nursing; * Active registration with **COREN**; * Experience in clinical areas involving medication administration/dispensing, surgical center, OPME, or auditing; * Basic Excel proficiency; **Desired Competencies and Knowledge:** * Strong writing and text composition skills; * Analytical ability and logical reasoning; * Concentrated attention and focus; * Agility and professional confidentiality; * Proficient typing skills; * Good interpersonal relationships and formal demeanor; * Knowledge of Law 9\.656; * Knowledge of RN 566/2022 (Service Response Timelines); * Knowledge of RN 395 (Procedure Requests and Authorizations); * Knowledge of RN 465 (Utilization Guidelines); * Knowledge of the National Interexchange Manual (MIN); * Knowledge of the Medical and Nursing Audit Manual (MAME); * Knowledge of TNUMM and CTNPM; * Experience analyzing authorization forms, authorized audits, and regulatory processes is a plus. **Work Location and Schedule:** * UNIMED GOIÂNIA – Administration, Praça Gilson Alves de Souza – Setor Bueno, Goiânia/GO; * Monday to Friday, from 08:00 to 18:00. **Additional Information** **Benefits:** * Meal and food allowance: R$ 1\.276,29; * Hazard pay: R$ 324,20; * Unimed health and dental plan; * Educational incentives; * Transportation allowance; * Health and quality-of-life initiatives; * Unimed University; * Wellhub (well-being benefit); * Structured career development plan; * Benefits offered by the Employees’ Association; * Individual Development Plan (PDI); * Breakfast or snack. #### **Our Mission** #### **To promote health through excellence in services, generating value and satisfaction for affiliated physicians and our customers, fulfilling our socio-environmental role with respect for cooperative principles.** #### **Our Vision** #### **To become a cooperative focused on financial sustainability and customer, physician, employee, and provider satisfaction.** #### **Our Values** #### **Ethics** #### **Transparency** #### **Integrity** #### **Quality** #### **Respect for Cooperative Principles** #### **Socio-Environmental Responsibility