Job Summary

Senior Consultant-National-Forensics-ASU - Forensics - Investigations & Compliance - Mumbai. National comprises of sector agnostic teams working across industries for a well rounded experience.

Responsibilities

- 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 the implementation and strengthening of Fraud, Waste & Abuse (FWA) management initiatives for a large government-sponsored health insurance scheme in Maharashtra. The position combines clinical expertise, medical audit capabilities, and technology-enabled fraud management approaches to protect public funds and improve scheme integrity. The selected candidate will support medical audits of claims, identify potential fraud patterns, contribute to anti-fraud technology development, and assist in strengthening fraud prevention, detection, deterrence, and monitoring mechanisms across the scheme. Key Responsibilities
- Conduct desk-based medical audits of claims submitted under the state health insurance scheme.
- Review clinical records, diagnostic reports, treatment documents, and claims data to identify indicators of fraud, waste, and abuse.
- Assess the clinical appropriateness of diagnoses, procedures, investigations, admissions, and length of stay against scheme guidelines and accepted clinical standards.
- Identify suspicious claim patterns, including unnecessary procedures, inflated billing, duplicate claims, inappropriate admissions, documentation discrepancies, and other aberrant utilization patterns.
- Support the development, validation, and refinement of technology-enabled anti-fraud solutions,



including fraud detection rules, triggers, alerts, and analytics models.
- Assist in implementation and continuous strengthening of the scheme's anti-fraud framework across prevention, detection, deterrence, and monitoring functions.
- Support triaging, clinical review, and escalation of suspected fraud cases with explicit medical rationale.
- Collaborate with analytics teams, technology partners, scheme authorities, hospitals, and other stakeholders to support fraud management initiatives.
- Contribute to fraud vulnerability assessments, trend analysis, and identification of emerging fraud risks.
- Prepare audit observations, case summaries, recommendations, and periodic reports for scheme authorities and project leadership.
- Support capacity-building initiatives, training programs, and awareness activities related to fraud prevention and claims integrity.
- Maintain accurate documentation and audit trails for reviews, investigations, and follow-up actions.

Qualifications
- MBBS

Experience
- Experience in medical audit, claims adjudication, utilization review, health insurance operations, fraud management, or healthcare quality review preferred. Exposure to government-funded health insurance schemes will be an advantage.

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 Forensics Consultant (Mumbai)
🏢 EY
📍 Mumbai