External Medical Auditor

Description

Job Summary: Porto Saúde’s Medical Audit Department seeks a professional to ensure quality of care, patient safety, and efficient allocation of resources, while fostering ethical partnerships with the accredited network. Key Highlights: 1. Strategic involvement in business sustainability and excellence in care. 2. Focus on quality of care, clinical safety, and resource efficiency. 3. Promotion of long-term partnerships with healthcare professionals and institutions. **What does the Medical Audit area do at Porto?** The Medical Audit Department at Porto Saúde plays a strategic and indispensable role in ensuring our business sustainability and guaranteeing excellence in care for our insured members. Our team operates directly on the front line, strengthening relationships with the accredited network—including hospitals, clinics, and healthcare service providers. The department’s core purpose is to safeguard the quality of care delivered, patient clinical safety, and the efficient allocation of healthcare resources. We ensure that all procedures, use of materials, and proposed treatments strictly align with the best and most up-to-date evidence-based medical practices, with regulatory guidelines issued by the National Supplementary Health Agency (ANS), and with institutional protocols. All this is carried out under the pillars of ethics, transparency, and constructive dialogue, promoting lasting, value-driven partnerships with healthcare professionals and institutions. **Responsibilities and Duties** * Concurrent and On-Site Auditing: Conduct daily technical visits to accredited hospitals to continuously monitor hospitalized patients, assessing quality of care, appropriateness of length of hospital stay, and clinical relevance of established treatments; * High-Complexity Evaluation: Conduct rigorous technical analyses of requests for complex surgical procedures, extensions of hospital stays, indications and use of OPME (Orthoses, Prostheses, and Special Materials), and therapies involving high-cost or immunobiological medications, verifying technical appropriateness and contractual coverage; * Medical Relationship and Negotiation: Serve as the primary technical liaison between the health plan operator and the provider, interacting courteously, ethically, and effectively with hospital auditors and attending physicians. * Preparation of Opinions and Reports: Issue well-founded technical opinions and prepare detailed reports regarding visits and audited processes; * These documents must clearly and legally support the operator’s decisions regarding authorizations or denials; * Compliance Assurance: Ensure all evaluations, workflows, and interactions fully comply with current ANS resolutions, the Health Procedures and Events List (Rol), and Porto’s strict compliance policies; * Strategic Cost Management: Proactively contribute to waste reduction, fraud prevention, and efficient management—ensuring financial efficiency never compromises patient safety or care quality. **Requirements and Qualifications** * **Education:** Completed undergraduate degree in **Medicine**, with active registration and financial/ethical regularity with the Regional Medical Council (CRM). * **Specialization:** Completed *Lato Sensu* postgraduate program in **Medical Auditing**, Healthcare Management, or Hospital Administration. * **Residency:** Completion of Medical Residency (clinical or surgical specialties are considered advantageous). * **Professional Experience:** Solid experience in medical auditing (external, concurrent, and/or retrospective). * **Advantage:** Prior experience with health plan operators (Supplementary Health) or hospital medical management in large-scale institutions. * **Fee Schedules:** Proficiency in CBHPM, TUSS, TISS, Simpro, and Brasíndice. * **Resource Management:** In-depth knowledge of Materials, OPME, Medications, and procedure coding. * **Regulation:** Thorough understanding of ANS regulations and the Health Procedures List (**ANS**). * **Communication:** Excellent verbal and written communication skills, with emphasis on technical persuasion. * **Emotional Intelligence:** Resilience in conflict management and empathy in interpersonal interactions. * **Analytical Profile:** Systemic business vision and agility in decision-making. * **Negotiation:** Ability to conduct technical discussions with firmness and diplomacy. * The auditor must lead technical discussions regarding discrepancies in medical conduct with attending physicians. The challenge lies in maintaining institutional and technical firmness while preserving **Porto Saúde**’s reputation and strong relationships with the accredited network; * Balance **financial sustainability** of the portfolio (sinistrality control and waste reduction) with the non-negotiable assurance of **patient safety** and clinical excellence; **Additional Information** **BENEFITS** **Flexible Meal and Food Allowance;** **Health Insurance Plan;** **Dental Insurance Plan;** **Wellhub and TotalPass;** **Exclusive Bio Ritmo Gym for Employees:** located at the Main Complex; **Profit-Sharing Program (PLR);** **Stock Ownership Program: Porto em Ação:** complementary to PLR until 2025; **Sand Courts and Multipurpose Courts:** located at the Main Complex; **Transportation Allowance;** **Van Transportation Services;** available at major access stations to Porto (Luz, Barra Funda, Santa Cecília, and Júlio Prestes); **Extended Parental Leave:** up to 40 days for all family configurations; **Extended Maternity Leave** of 6 months; **Medical Outpatient Clinic with Specialties:** located at the Main Complex and Barra Funda; **Childcare or Babysitter Assistance;** **Life Insurance;** **Private Pension Plan – PortoPrev;** **Discounts on Products and Services;** **Scholarship Program: Reimbursement for undergraduate, postgraduate, or MBA studies;** **Monthly Running Subsidy:** supporting major street races in São Paulo; **Language Reimbursement (English or Spanish);** **Teatro Porto:** exclusive sessions for employees; **Library;** **Rest Room:** at the Main Complex; **Game Room:** at the Main Complex; **Massage and Podiatry Services:** at the Main Complex; **Work Location: Campos Eliseos, with external activities required.** **Work Model: In-person** Porto is far more than an insurance company: it is a vast ecosystem leveraging technology to create solutions across four business verticals: **Porto Bank, Porto Saúde, Porto Seguro, and Porto Serviço**. The reputation and recognition earned over more than seven decades reinforce Porto’s stature—a reference company in business, built by and for people. Here, the pride of being part of a solid, ethical organization beats in the hearts of 13,000 employees—**an organization that transforms dreams into fantastic realities** for over 15.8 million customers. We operate through more than 101 branches and regional offices across Brazil. Learning is embedded in our DNA, and here you’ll find **incentives, tools, and supportive colleagues to learn and grow every day**, in an environment of inclusion and security where everyone can be—and take pride in being—who they are, promoting respect and **living holistically and with wellbeing in a genuinely human company.** **DIVERSITY & INCLUSION AT PORTO** At Porto, we value diversity and believe a plural team is essential to the development of our entire business, society, and each individual—because we understand that every person is unique in building a more innovative and inclusive environment. Together, we work daily to build a safe, free, and welcoming space—with greater plurality and respect. Therefore, we **strongly encourage applications from women, Black and Indigenous individuals, persons with disabilities, and LGBTQIA+ individuals** for all our open positions.