Job Summary
The Medical Expert will leverage clinical knowledge and healthcare domain expertise to support healthcare analytics, medical review processes, fraud detection initiatives, and data-driven decision making. The role involves interpreting medical information, validating healthcare claims and records, identifying anomalies, and collaborating with analytical teams to improve healthcare outcomes and operational effectiveness. The Medical Expert will provide clinical and claims-domain expertise for fraud rule development, HBP package interpretation, medical plausibility checks, focused on AB-PMJAY
Key Responsibilities
- Review and interpret clinical, medical, and healthcare-related data.
- Provide medical expertise for healthcare analytics, fraud detection, and investigation initiatives.
- Assess healthcare claims, treatments, diagnoses, and medical procedures for accuracy and compliance.
- Collaborate with data analysts, data scientists, and business teams to translate clinical requirements into analytical solutions.
- Identify trends, patterns, and potential risks through healthcare data analysis.
- Support development and validation of healthcare fraud, waste, and abuse detection models.
- Prepare medical insights, reports, and recommendations for stakeholders.
Required Skills & Competencies
- Knowledge of AB-PMJAY / HBP packages / TMS workflows.
- Experience with TPA, insurer, payer-side, provider-side or government health scheme claims review.
- Exposure to medical audit, utilisation review, claim adjudication, healthcare fraud analytics or fraud/waste/abuse detection.
- Strong understanding of healthcare systems, clinical workflows, and medical practices. Knowledge of healthcare claims, diagnosis codes (ICD), procedure codes (CPT/HCPCS), and payer processes.
- Proficiency in healthcare data analysis and reporting tools. Understanding of statistical and analytical methodologies used in healthcare analytics and fraud detection.
- Strong analytical and problem-solving skills. Excellent communication and stakeholder management abilities.
- Ability to interpret complex clinical information and translate it into business insights.
- Preferred Skills Experience in healthcare analytics, fraud detection, utilization review, or medical auditing. Exposure to SQL, Excel, Power BI, Tableau, SAS, Python, or other analytical tools. Familiarity with healthcare regulations, payer systems, and reimbursement processes.
Experience
- Minimum 5-8 years of experience in healthcare, health insurance, claims management, medical review, medical audit, utilisation review, hospital operations or government health schemes.
- Knowledge of AB-PMJAY / TPA / insurer / payer-side claims review will be preferred.
- Experience in HBP package validation, preauthorisation review, claim adjudication, procedure/package validation or healthcare fraud analytics will be an added advantage.
Key Deliverables
- Accurate clinical reviews and medical assessments.
- Actionable healthcare insights and recommendations.
- Identification of potential fraud, waste, and abuse cases.
- Support for healthcare analytics and operational improvement initiatives.
- Timely completion of medical reviews and reporting requirements. HBP/package interpretation and clinical exclusion logic.
- Medical rationale for rule documentation, dashboards, reports and client discussions.
- Actionable clinical insights to support healthcare fraud analytics and operational decision making.
Pay: ₹50,000.00 - ₹100,000.00 per month
Benefits:
- Health insurance
- Paid time off
Work Location: In person
