Job Summary

Senior - Investigations &

- Compliance - Gurgaon

Responsibilities Technical Excellence

- About the Role EYs 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.

Qualifications

- Educational Qualifications - Essential: MBBS from a recognized Indian university/institution (FMGs will not be considered) - Desirable: MD or Postgraduate Medical Qualification from a recognized university/institution.

Experience

- Experience Requirements Candidates across the following experience bands are required: o 3 to 6 years of experience. o Experience 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 cooperative 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.

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

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