Conduct analysis, monitoring, and control of healthcare claims, ensuring the correct application of contractual, regulatory, and healthcare rules. Identify deviations, prevent fraud, improve service efficiency, and reduce waste, contributing to the financial sustainability and quality of care provided by the health plan operator. **Main Responsibilities** * Perform technical analysis of claims (consultations, exams, SAD, hospitalizations, and surgical procedures). * Evaluate inconsistencies, atypical patterns, and significant variations in healthcare behavior. * Identify risks of overbilling, improper requests, duplications, and ineligible charges. * Refer suspicious cases to Medical Audit when applicable. * Analyze healthcare KPIs such as frequency, average cost, claim rates per beneficiary and provider. * Monitor indicators such as "exams per consultation", "self-generated SAD", hospitalizations, recidivism, and above-average patterns. * Prepare periodic monitoring and trend reports. * Investigate indications of fraud, abuse, and irregularities in bills and requests. * Conduct comparative analyses with market standards and specialty parameters. * Record and report suspected cases to responsible departments. * Collaborate with Medical Audit, Medical Billing, Network Management, and Utilization Review to resolve discrepancies. * Support negotiations with providers. * Suggest improvements in claims analysis workflows and healthcare controls. * Support digital transformation and process automation initiatives. * Participate in developing utilization policies and internal clinical guidelines. **Job Requirements** **Education:** * Bachelor's degree in Administration, Health Management, Nursing, Economics, Actuarial Science, or related fields. **Experience:** · Experience in health plans, auditing, utilization review, medical billing, or healthcare data analysis. · Experience evaluating claims, invoices, requests, and healthcare protocols. **Desirable Knowledge:** * ANS regulations and supplementary healthcare rules. * Intermediate to advanced Office/Excel skills. * Knowledge of network management systems or TISS/TUSS standards. * Understanding of healthcare utilization review, auditing, and medical billing processes. * Intermediate/advanced Excel and BI tools. * Analysis of claim rates, healthcare costs, and performance indicators. **Behavioral Competencies** * Negotiation and assertive communication skills. * Ability to build trust-based relationships. * Analytical mindset and results orientation. * Organization and priority management. * Consultative and collaborative attitude. * Proactivity and focus on problem resolution. * Analytical thinking and attention to detail. * Clear and assertive communication. * Ethical conduct and critical thinking. * Proactivity and solution-focused mindset. * Organization and management of multiple demands. * Ability to work collaboratively across departments. **Technical Competencies** * Claims and healthcare pattern analysis * Knowledge of coverage rules and clinical guidelines. * Interpretation of medical bills and TUSS/CBHPM codes. * Reading and interpreting indicators and dashboards. * Knowledge of audit and utilization review processes Employment type: Full-time CLT Salary: R$3,800.00 - R$4,500.00 per month Benefits: * Medical insurance * Life insurance * Meal allowance * Transportation allowance