Job Summary: Professional responsible for managing authorization workflows, technical analysis and reimbursement processes, regulatory and judicial compliance, regulation and auditing, as well as strategy and reporting within the healthcare domain. Key Highlights: 1. Authorization and Technical Analysis Workflow Management 2. Regulatory and Judicial Compliance in Supplementary Health 3. Development of Management Strategies and Performance Indicators Description: Required Qualifications Education and Technical Knowledge * Higher Education Degree: Preferably in healthcare-related fields (Medicine, Nursing, Pharmacy, Dentistry) or in Law with specialization in healthcare. * Technical Knowledge: Proficiency in supplementary health legislation, including ANS Normative Resolutions, and especially the ANS List of Procedures and Health Events. * Systems: Familiarity with health plan operator management systems (authorization, claims, eligibility) and data analysis tools. Preferred Qualifications * Postgraduate degree or specialization in Healthcare Management, Supplementary Health Regulation, or Healthcare System Auditing. * Prior experience working within the Unimed system. * Experience managing outsourced teams. Responsibilities and Duties * Authorization Workflow Management: * Manage and audit the complete workflow of medical requests (surgeries, therapies, examinations, OPME/Materials, Special Medications). * Ensure strict adherence to maximum service deadlines established by ANS, both for local clients and those under inter-operator agreements. * Technical Analysis and Reimbursement: * Lead technical analysis of reimbursement requests, verifying coverage eligibility, value compatibility, and contractual/regulatory compliance. * Manage the denial process, ensuring all decisions are legally and contractually justified, with a high rate of successful justification. * Regulatory and Judicial Compliance: * Coordinate analysis of cases escalated via ANS Preliminary Mediation Notice (NIP) and Ombudsman channels. * Prepare technical defenses and ensure timely, accurate responses per regulatory requirements. * Serve as the focal point for the Legal Department, providing specialized support and expert opinions for complying with or contesting judicial decisions (injunctions), thereby mitigating risks to the Operator. * Regulation and Auditing: * Manage key regulatory mechanisms such as Medical Boards and Medical Expertise. * Develop and implement clear criteria for analysis and decision-making in highly complex or exceptional cases not covered by the ANS List. * Maintain critical interfaces with Account Auditing, OPME Management, and Inpatient Patient Management. * Strategy and Reporting: * Prepare management reports and performance indicators. * Present and defend Health Technology Assessment (HTA) analysis reports before the Technical-Scientific Committee and the Regulation Committee. * Evaluate network adequacy based on reimbursement request analysis, proposing action plans jointly with Network Management. 2512120202501915578
João Silva
Indeed · HR
João Silva
Indeed · HR
