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This Senior Consultant role is within our National Forensics - Investigations & Compliance team in Gurgaon. The team works across various industries, providing a well-rounded experience. We specialize in helping organizations protect and restore their reputation by investigating facts, resolving disputes, and managing regulatory challenges. Our integrated approach enhances governance, controls, culture, and data insights to safeguard financial and brand reputations, building trust in capital markets worldwide.

You will play a key role in supporting Fraud, Waste & Abuse (FWA) management for government-funded health insurance schemes. This involves leveraging clinical expertise, medical audit capabilities, and data-driven strategies to ensure scheme integrity. Your responsibilities will include developing and validating fraud detection mechanisms, conducting clinical audits of claims, and providing technical support to claims adjudication processes.

Key tasks encompass desk-based medical audits, identifying indicators of fraud and abuse such as inappropriate billing and documentation inconsistencies, and assessing clinical appropriateness against established protocols. You will contribute to strengthening claims adjudication and fraud management, support investigations, and collaborate with various stakeholders including scheme authorities and analytics teams. The role also involves delivering technical orientations, preparing comprehensive reports, and continuously improving fraud prevention strategies.

To excel in this role, you should possess an MBBS degree from a recognized Indian university. A desirable qualification includes an MD or other postgraduate medical qualification. Experience in clinical practice, hospital operations, medical audits, health insurance, public health programs, or related healthcare domains is preferred.

We seek individuals who can collaborate effectively, deliver insightful solutions to complex problems, and work adeptly across client departments while adhering to commercial and legal requirements. An agile, curious, mindful, and adaptable approach with sustained positive energy is highly valued.