Senior Consultant, Forensics

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.

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.

Requirements & Tech Stack

Experience in clinical practice, hospital operations, medical audits, health insurance, public health programs, or related healthcare domains preferred.

Qualifications

• Essential: MBBS from a recognized university/institution.
• Desirable: Postgraduate qualification in a clinical discipline, Public Health, or related field.

Skills and Attributes

• Ability to work in a collaborative manner to provide services across multiple client departments while following commercial and legal requirements.
• Practical approach to solving issues and complex problems with the ability to deliver insightful and practical solutions.
• Agile, curious, mindful, and able to sustain positive energy.
• Adaptable and creative in approach.