Senior Forensics Consultant
Ernst Young · Mumbai · onsite · Posted 43d ago
Undisclosed8–12 yrsfulltimeSourced from
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About this role
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 clear 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.
- MBBS
- 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.
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.
Sourced from naukri
Skills
legal counselAgileFraud PreventionFraud ManagementcounselForensicsmbbsfraud detectiondiagnosticauditsAnalyticsAdjudicationCapital MarketsHealthcareoperationsLegalcomplianceAdmissionsInsurance Operations
About Ernst & Young
Ernst Young
Management Consulting
44k+
employees
2002
24 years old
Gurgaon / Gurugram, Haryana
India
₹15.3L PA avg
Avg at Ernst & Young
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