EY India | Senior Consultant - Forensics - National - ASU - Forensics - Investigations & Compliance - Mumbai

Key responsibilities

• 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.
• Skills and attributesTo qualify for the role you must haveQualification •\tEssential: MBBS from a recognized university/institution. •\tDesirable: Postgraduate qualification in a clinical discipline, Public Health, or related field.
• You will need a practical approach to solving issues and complex problems with the ability to deliver insightful and practical solutions.
• Investigations & Compliance : Successful organizations depend on their reputation for keeping promises, respecting laws and behaving ethically to maintain stakeholder trust.
• 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

• Experience Up to 3 years of experience post essential qualification . o.
• Experience in clinical practice, hospital operations, medical audits, health insurance, public health programs, or related healthcare domains preferred.

EY (Ernst & Young)

EY is one of the Big Four professional services networks, providing assurance, tax, consulting and strategy-and-transactions services. The network in its present form came from the 1989 merger of Ernst & Whinney and Arthur Young.

In India, EY member firms and EY Global Delivery Services employ large finance teams. Typical openings for chartered accountants and finance professionals are in financial accounting advisory (FAAS), audit, tax, risk and transaction services.

• Industry: Assurance, tax, consulting and transactions (Big Four)
• Headquarters: London, UK
• In India: EY member firms and EY Global Delivery Services centres in several Indian cities