Senior Project Consultant-Business Consulting PI-GOV-CNS-BC-Transformation Delivery-New Delhi

Requisition Id: 1727055

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 Project Consultant-GOV-Business Consulting PI-CNS - BC - Transformation Delivery - New Delhi

GOV :

Our Global Government & Public Sector (GPS) is a network of highly skilled professionals dedicated to serving our clients by bringing best-in-class international experience and insight combined with local knowledge to solve the most critical problems facing governments today. We actively focus on building solutions that help public sector entities face the challenges of the future and reinvent themselves.

Digital transformation is not just about new technologies; it involves an overhaul of organizational structures, governance, work processes, culture and mindset. It also means realizing a wider vision of relationships and business models that will redesign how public services function.

To achieve this vision, we help clients balance strategic choices to re-ignite performance. We have developed a suite of cross-service line strategic solutions that align with our client priorities.

We have a proud record of helping governments meet their challenges head-on, and we work closely with them to build a world that works better for all citizens.

CNS - BC - Transformation Delivery :

EY Consulting is building a better working world by transforming businesses through the power of people, technology and innovation. Our client-centric approach focuses on driving long-term value for our clients by solving their most strategic problems. EY Consulting is made up of three sub-service lines: Business Consulting (including Performance Improvement and Risk Consulting), Technology Consulting and People Advisory Services. 

Business Consulting works with clients to reimagine or transform their business purpose and model; create growth; manage cost and efficiency; respond to market pressures and regulation; and resolve operational challenges. The scope of this team encompasses innovation, strategy and purpose, through deep functional experience in business transformation, finance, supply chain and operations, providing support for the complex and large-scale program and portfolio management.

It has multiple fields of play such as:

Finance Consulting - helps assess and transform our clients' finance function to improve performance and effectiveness. We help organizations implement service and cost improvement initiatives, and embed a performance management process and culture that unites the business around its core objectives.

Business Transformation - a m?ultidisciplinary competency, gathering capabilities in transformation architecture, experience design, business design and transformation execution to problem-solve, design and deliver large scale, multi-year, multi-stakeholder transformation programs.

Supply Chain and Operations - we provide a unique combination of industry-specific, strategic, operational and financial insights, digital technology advances and strategic alliance partners to deliver better outcomes and also help clients effect fundamental change in their operations’ performance to support sales growth, become more cost competitive, minimize risk and ensure operational resilience.

Your key responsibilities

Technical Excellence

• Consultant – Claims Adjudication & Audit (CAA) Role Purpose The Consultant – Claims Adjudication & Audit will support the effective and consistent adjudication of healthcare claims across convergence schemes. The role will be responsible for conducting medical and technical audits, reviewing processed claims, identifying gaps or irregularities, and strengthening the capabilities of claims adjudicators and other scheme stakeholders. The incumbent will help ensure that claims are processed in accordance with applicable scheme guidelines, medical protocols, benefit packages, standard operating procedures and established controls. Key Responsibilities A. Claims Adjudication and Review Review samples of claims processed by Claims Processing Doctors or other designated claims adjudicators. Assess the medical necessity, appropriateness and admissibility of claims in accordance with scheme guidelines. Verify clinical documentation, diagnosis, treatment, procedures, length of stay and supporting records. Identify discrepancies, inconsistencies, incorrect adjudication decisions and potential deviations from prescribed processes. Provide recommendations for corrective action and improvement of claims-adjudication quality. Support the uniform interpretation and implementation of claims-processing guidelines across schemes and stakeholders. B. Medical and Technical Audit Conduct medical audits and technical audits of processed healthcare claims. Undertake random checks of claims processed by Claims Processing Doctors. Support technical audits of Implementation Support Agencies or other agencies involved in claims processing. Conduct or support death audits, including examination of the relevant medical and claims documentation. Document audit findings, observations, exceptions and recommendations in a clear and structured manner. Track the closure of audit observations and support the implementation of corrective and preventive actions. Escalate material medical, operational or compliance concerns to the appropriate authority. C. Training and Capacity Building Conduct technical training sessions for claims adjudicators and other relevant officials. Train and re-train stakeholders such as: Claims Processing Doctors; Sanctioning Authorities; Directors/Officials responsible for medical review; Nodal Officers; Drawing and Disbursing Officers; and Other stakeholders involved in claims adjudication. Develop or contribute to training materials, case studies, reference documents, standard operating procedures and frequently asked questions. Train master trainers for different convergence schemes. Support the capacity-building team in assessing training needs and improving the technical competence of claims-adjudication personnel. Provide clarifications and technical guidance on complex medical claims and adjudication scenarios. D. Quality Assurance and Process Improvement Monitor the quality and consistency of claim-adjudication decisions. Analyse recurring adjudication errors, medical discrepancies and process gaps. Recommend improvements to claims-adjudication workflows, audit protocols and review mechanisms. Support the standardisation of claims-review practices across schemes. Contribute to the development or revision of medical audit checklists, adjudication manuals and quality-control frameworks. Assist in defining indicators for measuring claims quality, accuracy and turnaround time. E. Fraud, Waste and Abuse Controls Identify suspicious clinical or claims patterns during medical and technical reviews. Flag cases that may indicate overbilling, unnecessary procedures, misrepresentation, upcoding, unbundling or other irregular claims practices. Coordinate with medical, analytics, forensic and fraud-control teams for further examination of suspicious cases. Provide medical inputs for the development and validation of claims triggers and risk indicators. Maintain confidentiality and follow applicable protocols when handling sensitive beneficiary, provider and claims information. F. Coordination and Reporting Coordinate with scheme managers, hospitals, claims-processing agencies, Implementation Support Agencies and other stakeholders. Prepare periodic audit reports, claims-quality summaries and presentations for management review. Maintain accurate records of claims reviewed, audits conducted, training delivered and actions taken. Participate in review meetings and present key findings, trends, risks and recommendations. Perform other responsibilities relating to claims-adjudication management, medical audit and capacity building, as assigned by the competent authority. 4. Essential Qualification MBBS degree from a recognised university or institution. 5. Desirable Qualification MD or an equivalent postgraduate medical qualification from a recognised university or institution. 6. Experience Requirements A minimum of 3 years and less than 6 years of post-qualification experience in one or more of the following areas: Healthcare practice; Health insurance; Medical or healthcare insurance services; Claims processing; Claims adjudication; Claims management; or Medical audit. Experience in government health schemes, large-scale healthcare programmes, third-party administration or public health insurance will be an advantage.

Skills and attributes

To qualify for the role you must have
Qualification

• MBBS and/or MD

Experience

• A minimum of 3 years and less than 6 years of post-qualification

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.

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