Job Summary: Nursing professional to perform analysis and adjustment of highly complex billing accounts, support analysts, and ensure compliance during audits, aiming to optimize processes. Key Highlights: 1. Reference for analysts and technical support regarding contractual questions 2. Analysis of highly complex accounts and audit of claim denials 3. Schedule management and follow-up on pending items **Responsibilities and Duties** * Serve as the reference point for analysts and report all requests/difficulties to the supervisor. * Analyze and adjust highly complex accounts: TMO, transplants, high-complexity surgeries, and hemodynamics. * Proactively identify priority accounts and accounts at risk of schedule delays, per supervisor guidance. * Delegate daily task assignments to analysts. * Support and guide analysts and the clinical team on technical and contractual questions related to each health plan. * Perform final review of physician fees. * Open system adjustment tickets. * Complete non-conformance spreadsheet. * Receive finalized accounts and organize them in audit rooms according to each health plan. * Schedule all weekly nursing, medical, and RAH audits. * Reach consensus with external auditors. * Always appeal denials that have a valid defense. * Escalate denials of any nature exceeding 5% of the account’s total value. * Open and track tickets until resolution of registration and commercial pending items. * Accurately code accounts after acceptance of applied denials and forward them for cleanup. * Release accounts for submission after RAH. * Perform account cleanup following acceptance of denials by the nurse auditor. * Accurately code in MV as indicated by the nurse auditor. **Requirements and Qualifications** If you aim to achieve outstanding results alongside people who dream big, work together, and grow together, our corporate area is the right place for you. To transform healthcare, you must: * Hold a Bachelor’s degree in Nursing. * Postgraduate degree in Auditing is desirable. * Knowledge of healthcare auditing, including legislation, regulations, and procedures. Experience in clinical care and skills in communication, critical analysis, and problem solving. * Proficiency in Microsoft Office Suite. **Additional Information** **Location: Brasília - DF** Minimum Education Level: Bachelor’s Degree * Universidade Rede Américas, Development Cycle * Health Program, based on 5 pillars * Career development, Technology/PMAX Academies, and Crescer Program within Rede Américas * Meal Allowance / Food Allowance or On-site Cafeteria (depending on location) * Telepsychology * Transportation Allowance and Performance Bonus (PPR) * Benefits may vary depending on job location and brand. * Health Insurance and Life Insurance * UAU Benefits Club and SESC benefits * TotalPass, primary care clinic, discounts on exams and vaccines
João Silva
Indeed · HR
João Silva
Indeed · HR
