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 o

📌 Medical Auditor (Delhi)
🏢 EY
📍 Delhi