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.
- Solid 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 an

📌 Medical Officer (Delhi)
🏢 Solutionec
📍 Delhi