The chance: Senior Project Consultant-GOV-Business Consulting PI-CNS - BC - Transformation Delivery - New Delhi

GOV :

Digital transformation is not just about new technologies; it involves an overhaul of organizational structures, governance, work processes, culture and mindset. It also means realizing a wider vision of relationships and business models that will redesign how public services function.

CNS - BC - Transformation Delivery :

Your key responsibilities

Technical Excellence

- Consultant Claims Adjudication & Audit (CAA) Role Purpose The Consultant Claims Adjudication & Audit will support the effective and consistent adjudication of healthcare claims across convergence schemes. The role will be responsible for conducting medical and technical audits, reviewing processed claims, identifying gaps or irregularities, and strengthening the capabilities of claims adjudicators and other scheme stakeholders. The incumbent will help ensure that claims are processed in accordance with applicable scheme guidelines, medical protocols, benefit packages, standard operating procedures and established controls. Key Responsibilities A. Claims Adjudication and Review Review samples of claims processed by Claims Processing Doctors or other designated claims adjudicators. Assess the medical necessity, appropriateness and admissibility of claims in accordance with scheme guidelines. Verify clinical documentation, diagnosis, treatment, procedures, length of stay and supporting records. Identify discrepancies, inconsistencies, incorrect adjudication decisions and potential deviations from prescribed processes. Provide recommendations for corrective action and improvement of claims-adjudication quality. Support the uniform interpretation and implementation of claims-processing guidelines across schemes and stakeholders. B. Medical and Technical Audit Conduct medical audits and technical audits of processed healthcare claims. Undertake random checks of claims processed by Claims Processing Doctors.



Support technical audits of Implementation Support Agencies or other agencies involved in claims processing. Conduct or support death audits, including examination of the relevant medical and claims documentation. Document audit findings, observations, exceptions and recommendations in a clear and structured manner. Track the closure of audit observations and support the implementation of corrective and preventive actions. Escalate material medical, operational or compliance concerns to the appropriate authority. C. Training and Capacity Building Conduct technical training sessions for claims adjudicators and other relevant officials. Train and re-train stakeholders such as: Claims Processing Doctors; Sanctioning Authorities; Directors/Officials responsible for medical review; Nodal Officers; Drawing and Disbursing Officers; and Other stakeholders involved in claims adjudication. Develop or contribute to training materials, case studies, reference documents, standard operating procedures and frequently asked questions. Train master trainers for different convergence schemes. Support the capacity-building team in assessing training needs and improving the technical competence of claims-adjudication personnel. Provide clarifications and technical guidance on complex medical claims and adjudication scenarios. D. Quality Assurance and Process Improvement Monitor the quality and consistency of claim-adjudication decisions. Analyse recurring adjudication errors, medical discrepancies and process gaps. Recommend improvements to claims-adjudication workflows, audit protocols and review mechanisms. Support the standardisation of claims-review practices across schemes. Contribute to the development or revision of medical audit checklists,



adjudication manuals and quality-control frameworks. Assist in defining indicators for measuring claims quality, accuracy and turnaround time. E. Fraud, Waste and Abuse Controls Identify suspicious clinical or claims patterns during medical and technical reviews. Flag cases that may indicate overbilling, unnecessary procedures, misrepresentation, upcoding, unbundling or other irregular claims practices. Coordinate with medical, analytics, forensic and fraud-control teams for further examination of suspicious cases. Provide medical inputs for the development and validation of claims triggers and risk indicators. Maintain confidentiality and follow applicable protocols when handling sensitive beneficiary, provider and claims information. F. Coordination and Reporting Coordinate with scheme managers, hospitals, claims-processing agencies, Implementation Support Agencies and other stakeholders. Prepare periodic audit reports, claims-quality summaries and presentations for management review. Maintain accurate records of claims reviewed, audits conducted, training delivered and actions taken. Participate in review meetings and present key findings, trends, risks and recommendations. Perform other responsibilities relating to claims-adjudication management, medical audit and capacity building, as assigned by the competent authority.

Skills and attributes

To qualify for the role you must have

Qualification

- MBBS and/or MD

Experience

- A minimum of 3 years and less than 6 years of post-qualification

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.

📌 Senior Project Consultant-Business Consulting -Transformation Delivery (New Delhi)
🏢 EY
📍 New Delhi