Adjudication Auditor
6 hours ago
Required Educational Qualification
Required Experience
Graduate degree in Medicine (MBBS) or in any other health sciences.
Desirable:
Certification in Medical Audit, Health Claims Processing, Fraud Risk Management, or Forensic Audit.
Required Experience :
Minimum 8 years of experience in healthcare claims adjudication, medical auditing, or fraud investigation in insurance or government health schemes.
- Experience in reviewing high-volume claims data and applying medical/insurance guidelines for adjudication.
Key Competencies
- Strong analytical and investigative skills.
- Proficiency in interpreting medical documentation and insurance guidelines.
- Knowledge of fraud detection methodologies and forensic auditing techniques.
- Excellent stakeholder engagement and report-writing skills.
Job Description/ Key Responsibility
I. Review and audit claims related to convergence scheme
II. Verify adherence to medical protocols, package rates, and pre-authorisation requirements.
III. Analyse claims data to identify patterns, anomalies, and potentially fraudulent activities.
IV. Coordinate with NAFU and converged ministry/department for investigation of suspected fraud cases.
V. Recommend enhancements to adjudication workflows to reduce errors and prevent fraud.
VI. Assist in developing anti-fraud policies, SOPs, and risk mitigation frameworks.
VII. Develop training material for adjudicators (ISAs) and fraud control teams (internal & external).
VIII. Conduct capacity-building workshops on adjudication quality and fraud prevention techniques.
IX. Maintain regular reports on audit findings, fraud cases, and resolution outcomes.
X. Provide evidence-backed inputs for decision-making at the national level.
