Senior Consultant - Forensics - National - ASU - Forensics - Investigations & Compliance - Mumbai

Requisition Id: 1735696

As a global leader in assurance, tax, transaction and advisory services, we hire and develop the most passionate people in their field to help build a better working world. This starts with a culture that believes in giving you the training, opportunities and creative freedom. At EY, we don't just focus on who you are now, but who you can become. We believe that it’s your career and ‘It’s yours to build’ which means potential here is limitless and we'll provide you with motivating and fulfilling experiences throughout your career to help you on the path to becoming your best professional self.

The opportunity : Senior Consultant-National-Forensics-ASU - Forensics - Investigations & Compliance - Mumbai

National :

National comprises of sector agnostic teams working across industries for a well rounded experience.

ASU - Forensics - Investigations & Compliance :

Successful organizations depend on their reputation for keeping promises, respecting laws and behaving ethically to maintain stakeholder trust. EY Forensic & Integrity Services professionals help organizations protect and restore enterprise and financial reputation. We assist companies and their legal counsel to investigate facts, resolve disputes and manage regulatory challenges. We put integrity at the heart of compliance programs to help better manage ethical and reputational risks. 

Our integrated approach ranges from enhancements in areas of perceived weakness or issues — including governance, controls, culture and data insights — to full organizational design and structural implementation. We want to help companies safeguard and restore financial and brand reputations. The insights and quality services we deliver help build trust and confidence in the capital markets and in economies the world over.

Your key responsibilities

Technical Excellence

• 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.

Skills and attributes

To qualify for the role you must have
Qualification

• MBBS

Experience

• o\tExperience in medical audit, claims adjudication, utilization review, health insurance operations, fraud management, or healthcare quality review preferred. o\tExposure 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.

What we offer

Fuelled by the brilliance of our people, EY has emerged as the strongest brand and the most attractive employer in our field, with market-leading growth over competitors. Our people work side-by-side with market-leading entrepreneurs, game-changers, disruptors, and visionaries. As an organization, we are investing more time, technology, and money than ever before in skills and learning for our people. At EY, you will have a personalized Career Journey and also the chance to tap into the resources of our career frameworks to better know about your roles, skills, and opportunities.

EY is equally committed to being an inclusive employer, and we strive to achieve the right balance for our people—enabling us to deliver excellent client service while allowing our people to build their careers as well as focus on their wellbeing.

If you can confidently demonstrate that you meet the criteria above, please contact us as soon as possible.

Join us in shaping the future with confidence. Apply Now