Medical Auditor

About This Role

This role supports Fraud, Waste, and Abuse (FWA) management initiatives within government-funded health insurance and healthcare schemes. It uses clinical expertise, medical audit capabilities, and data-driven methods to enhance scheme integrity. The position will aid in developing and validating fraud detection mechanisms, performing clinical claims audits, offering technical support for claims adjudication, and contributing to capacity-building and fraud prevention efforts. Depending on experience, responsibilities may range from claims review and audit support to leading fraud management initiatives and engaging stakeholders.

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

Requirements

• MBBS from a recognized Indian university/institution (FMGs will not be considered)
• Up to 3 years of experience in clinical practice, hospital operations, medical audits, health insurance, public health programs, or related healthcare domains preferred (for Medical Auditor - 1)
• 3 to 6 years of experience in medical audits, claims review, utilization review, healthcare fraud management, health insurance, or government healthcare schemes preferred (for Medical Auditor - 2)
• 5 or more years of experience, with demonstrated experience in fraud audit, fraud management, claims adjudication, medical audit, healthcare fraud investigations, or health insurance program management (for Medical Auditor - 3)