Medical Consultant- Frauds

  • GiZ
  • Job Reference Code: MCF-SHA-MP
Last date of application
 14-Nov-21 23:59 HR

JOB DESCRIPTION

Medical Consultant– Frauds, State Health Department, Madhya Pradesh
 

1. POSITIONS VACANT: Medical Consultant– Frauds, State Health Department, Madhya Pradesh

2. ORGANIZATION BACKGROUND:

The Indo-German Universal Health Coverage Programme (IGUHCP) is part of Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Germany’s enterprise for international cooperation. GIZ works with Indian ministries at the Centre and State Governments for implementation of bilateral cooperation projects.

IGUHC works closely with National Health Authority under Ministry of Health and Family Welfare (MoHFW) and with selected state governments to provide policy advise and implementation support in the areas of Universal Health Coverage, Health Systems Strengthening, Social Health Insurance and health security. Other government ministries/agencies with which IGUHC works closely are NITI Aayog, ESIC, Ministry of Labour and Employment (MoLE), ICMR etc.

In the course of the COVID-19 pandemic, the programme is supporting the Governments at national and State level in implementing additional measures. The objective of these measures is to increase COVID-19 testing and treatment measures across the different regions.

As part of this Professional Programme it is proposed to hire a consultant who will support the  SAFU in the State Health Agency for the management of Frauds under PMJAY. The consultant will be expected to support the development of Anti-fraud policies for PM-JAY for the state of Madhya Pradesh.

3. JOB DESCRIPTION/ RESPONSIBILITIES:

The Consultant will be responsible for supporting the State Health Agency with technical inputs on frauds related matters for the implementation of PMJAY. The Consultant will work under the direct supervision of the reporting officer assigned by the State Health Agency.


Key Responsibilities:

(1) To make himself/herself thoroughly familiar with the AB PM-JAY processes. To acquire an in-depth understanding of the guidelines of the scheme and role of various stakeholders;

(2) Support the SHA  in fraud detection in the empanelled hospitals under PMJAY;

(3) Identification of the alerts in the system that helps to monitor the occurrence of frauds and developing methods of preventing these frauds;

(4) Development/ updation of various guidelines/ advisories and policy documents under the scheme for fraud control related matters;

(5) Ensure smooth communication coordination between different Divisions, Districts and sections of SHA, such as State Coordination, IT, DQAC and Operations, as well as with the districts;

(6) Involve and engage in various committees and sub-committees of SAFU; Support in the development of anti-fraud policies and guidelines (aligned to NHA Anti-Fraud Guidelines) as per the  National Anti-Fraud Framework, accounting for the implementation specificities of its respective State/UT; 

(7) Support in ensuring that all contracts signed by the SHA with any party (Insurer, ISA, TPA, provider, IT agency, etc.) include adequate anti-fraud provisions, safeguards, disincentives and penalties that are enforceable. All references for this should be drawn from model contracts developed by the NHA;

(8) Monitor the prevention of provider empanelment fraud by following laid down guidelines and procedures in transparent and efficient manner;

(9) Support the SHA in ensuring compliance to beneficiary identification/verification guidelines, preauthorization and claims adjudication, audit and payment guidelines. Along with implementation of bio-metric authentication of beneficiary at the time of admission and discharge;

(10) Managing the implementation of system built controls and checks in IT system, and generate real time alerts to stakeholders. Supporting in the limited/restrict the use of ‘unspecified’ packages;

(11) Undertake any other assignment/ responsibility given by SHA. Support in building anti-fraud awareness, public messaging.


4. QUALIFICATION, SKILLS AND EXPERIENCE: 
     
Qualifications:

Graduation or higher qualification in MBBS from a recognized university or institute.


Experience:

(1) 3-4 years of relevant post qualification professional experience in working for health insurance scheme or private health insurance companies;

(2) Experience of supporting the frauds unit in the government health insurance schemes or private insurance companies.

Skills and Competencies:

(1) Strong verbal and written communication and presentation skills;

(2) Computer literate with knowledge and experience of MS Office, Excel and PowerPoint;

(3) Proficient in drafting notes and letters in English and Hindi, with emphasis on spelling, punctuation, grammar and other language skills;

(4) Language skills in English and Hindi.

5. VACANCY DETAILS: One vacancy          

6. COMPENSATION OFFERED:

The offer made to the selected candidate shall be commensurate with qualifications, experience, and salary history.

7. NATURE OF ENGAGEMENT:

The Consultant shall be hired on a consultancy contract through Strategic Alliance Management Services P Ltd. (SAMS), a respected HR Agency.

8. LOCATION: The Consultant will be placed in State Health Agency of Madhya Pradesh.

9. CONTRACT TYPE AND PERIOD:

The post-holder shall be engaged on a consultancy contract, initially for a period of one year, extendable thereafter, on the basis of performance and approval by SHA.

10. REFERENCE: MCF-MP

11. CONTACT INFORMATION:
Team SAMS
Strategic Alliance Management Services P Ltd.
1/1B, Choudhary Hetram House, Bharat Nagar
New Friends Colony, New Delhi 110 025
Phone Nos.: 011-41011564/65; 4081 9900

12. LAST DATE FOR APPLICATIONS:

Eligible candidates interested in the position are requested to apply using the link https://recruitment.samshrm.com/Jobs/GIZ by or before November 14, 2021