Medical Auditor

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 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,

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 Requirements

Candidates across the following experience bands are required:

1. Medical Auditor - 1 (No. of vacancies = 1)

Up to 3 years of experience,

Experience in clinical practice, hospital operations, medical audits, health

2.

insurance, public health programs, or related healthcare domains preferred, Medical Auditor - 2 (No. of vacancies = 1)

3 to 6 years of experience,

Experience in medical audits, claims review, utilization review, healthcare fraud

3.

management, health insurance, or government healthcare schemes preferred, Medical Auditor - 3 (No. of vacancies = 1)

5 or more years of experience,

Demonstrated experience in fraud audit, fraud management, claims adjudication,

medical audit, healthcare fraud investigations, or health insurance program management,

• Experience in designing or validating fraud detection controls, conducting

training programs, and managing stakeholder interactions preferred,

Skills & Competencies

• Strong clinical knowledge and medical judgment,
• Understanding of healthcare fraud, waste, and abuse typologies,
• Knowledge of claims adjudication and healthcare reimbursement processes,
• Strong analytical and problem-solving abilities,
• Attention to detail and ability to evaluate complex medical records,
• Ability to work effectively with data analytics and technology teams,
• Strong written and verbal communication skills,
• Stakeholder management and coordination capabilities,
• Proficiency in report writing and documentation,

Preferred Experience

• Experience with government healthcare schemes, including PM-JAY, state health

insurance schemes, or related programs,

• Experience in medical audits, utilization review, claim adjudication, fraud analytics, or

healthcare quality assurance,

• Exposure to healthcare data analysis and technology-enabled fraud detection tools,