High-Cost Funds Analyst

Description

Job Summary: Professional to perform administrative audits, claim denial analysis, support in treatment and billing analysis, system management, and training. Key Highlights: 1. Experience in administrative audits and claim denial analysis. 2. Support in treatment analysis and billing processes. 3. System management and configuration (Sys-On, SGMED). Description: REQUIREMENTS: Currently enrolled in a Bachelor's degree program Proficiency in the Sys\-On system DESIRED: Completed Bachelor's degree Knowledge of oncology protocols * Collaborate with Accounts Analysts to conduct administrative audits and analyze claim denials for accounts submitted by the Shareholders; * 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 the Funds; * Populate strategic and operational indicators, action plans, and maintain updated workflows, SOPs, and forms; * Conduct training sessions and meetings with Shareholders 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 user access and permissions within the Sys\-On system; * Register, update, and monitor DUTs (Technical Justification Documents) in the Sys\-On system for use in medical opinions. Also monitor ANVISA’s incorporation of new medications or updates to drug package inserts, register them in the Sys\-On system to update the drug database and support medical opinions; * Analyze medical audit opinions to identify non-conformities and/or violations of administrative regulations that may cause losses to the Shareholders; * Perform Third-Opinion reviews; * Develop indicator analyses and plans for the Program’s Critical Analysis; * Generate managerial reports on reimbursement payments due to Shareholders 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 by period/competency for value reconciliation and submission of payment reports to Shareholders and Providers; * Conduct training and system implementation for new FAC Providers; * Analyze, interpret, and review contracts related to negotiations with new Providers and addenda; * Provide support to Shareholders and 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 reasons for claim denials 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