Other locations: Primary Location Only
Requisition Id: 1736278
As a global leader in assurance, tax, transaction and advisory services, we hire and develop the most passionate people in their field to help build a better working world. This starts with a culture that believes in giving you the training, opportunities and creative freedom. At EY, we don't just focus on who you are now, but who you can become. We believe that it’s your career and ‘It’s yours to build’ which means potential here is limitless and we'll provide you with motivating and fulfilling experiences throughout your career to help you on the path to becoming your best professional self.
The opportunity : Senior Consultant-National-Forensics-ASU - Forensics - Investigations & Compliance - Gurgaon
National :
National comprises of sector agnostic teams working across industries for a well rounded experience.
ASU - Forensics - Investigations & Compliance :
Successful organizations depend on their reputation for keeping promises, respecting laws and behaving ethically to maintain stakeholder trust. EY Forensic & Integrity Services professionals help organizations protect and restore enterprise and financial reputation. We assist companies and their legal counsel to investigate facts, resolve disputes and manage regulatory challenges. We put integrity at the heart of compliance programs to help better manage ethical and reputational risks.
Our integrated approach ranges from enhancements in areas of perceived weakness or issues — including governance, controls, culture and data insights — to full organizational design and structural implementation. We want to help companies safeguard and restore financial and brand reputations. The insights and quality services we deliver help build trust and confidence in the capital markets and in economies the world over.
Your key responsibilities
Technical Excellence
- About the Role EY's Forensic & Integrity Services helps organizations strengthen trust by combating fraud, improving compliance, and enabling data-driven decision-making. This role will support Fraud, Waste & Abuse (FWA) management initiatives under government-funded health insurance and healthcare schemes by leveraging clinical expertise, medical audit capabilities, and data-driven approaches to strengthen scheme integrity. The position will support the development and validation of fraud detection mechanisms, conduct clinical audits of claims, provide technical support to claims adjudication processes, and contribute to capacity-building and fraud prevention initiatives. Depending on experience, the selected candidate may undertake responsibilities ranging from claims review and audit support to leading fraud management initiatives and stakeholder engagement. Key Responsibilities
- Conduct desk-based medical audits and reviews of claims submitted under government healthcare schemes.
- Identify indicators of fraud, waste, and abuse, including inappropriate billing, medically unnecessary procedures, documentation inconsistencies, duplicate claims, and other anomalous patterns.
- Support development, refinement, and validation of fraud detection triggers, business rules, and control mechanisms.
- Assess the clinical appropriateness of diagnoses, procedures, admissions, investigations, and length of stay against established treatment protocols and scheme guidelines.
- Provide clinical insights and technical support to strengthen claims adjudication and fraud management processes.
- Support investigation, triaging, escalation, and resolution of potentially suspect claims.
- Collaborate with scheme authorities, healthcare providers, analytics teams, technology teams, and other stakeholders to support fraud control initiatives.
- Deliver technical orientation and capacity-building support for claims adjudicators and relevant program personnel.
- Prepare audit observations, case documentation, analytical reports, and periodic management reports.
- Contribute to continuous improvement of fraud prevention, detection, and control mechanisms across healthcare schemes.
- Undertake other activities related to Fraud, Waste & Abuse management, medical audits, and scheme integrity as assigned.
Skills and attributes
To qualify for the role you must have
Qualification
- Educational Qualifications •\tEssential: MBBS from a recognized Indian university/institution (FMGs will not be considered) •\tDesirable: MD or Postgraduate Medical Qualification from a recognized university/institution.
Experience
- Experience Requirements Candidates across the following experience bands are required: o\t3 to 6 years of experience. o\tExperience in medical audits, claims review, utilization review, healthcare fraud management, health insurance, or government healthcare schemes preferred.
What we look for
People with the ability to work in a collaborative manner to provide services across multiple client departments while following the commercial and legal requirements. You will need a practical approach to solving issues and complex problems with the ability to deliver insightful and practical solutions. We look for people who are agile, curious, mindful, and able to sustain positive energy, while being adaptable and creative in their approach.
What we offer
Fuelled by the brilliance of our people, EY has emerged as the strongest brand and the most attractive employer in our field, with market-leading growth over competitors. Our people work side-by-side with market-leading entrepreneurs, game-changers, disruptors, and visionaries. As an organization, we are investing more time, technology, and money than ever before in skills and learning for our people. At EY, you will have a personalized Career Journey and also the chance to tap into the resources of our career frameworks to better know about your roles, skills, and opportunities.
EY is equally committed to being an inclusive employer, and we strive to achieve the right balance for our people—enabling us to deliver excellent client service while allowing our people to build their careers as well as focus on their wellbeing.
If you can confidently demonstrate that you meet the criteria above, please contact us as soon as possible.
Join us in shaping the future with confidence. Apply Now
