Consultant Medical Officer

JOB SUMMARY
The Government of India announced Ayushman Bharat in 2018. Ayushman Bharat, a major health sector reform, aims at making interventions in primary, secondary, and tertiary care systems, covering both preventive and promotive health, to address healthcare holistically. The program includes two major health initiatives, namely, Health and Wellness Centers and Pradhan Mantri Jan Arogya Yojana (PMJAY). The PM-JAY will cover over 10 crore (one hundred million) poor and vulnerable families (approximately 50 crore (five hundred million) beneficiaries), providing coverage up to 5 lakh rupees ($7,100) per family per year for secondary and tertiary care hospitalization.

ACCESS Health provides implementation support to the State Health Agencies in Uttar Pradesh in the implementation of Pradhan Mantri Jan Arogya Yojana (PM-JAY) towards building state leadership in evidence-based implementation, use of efficient, multisectoral, and cost-effective interventions for increasing beneficiaries’ access to quality healthcare, improved experience, and reduced out-of-pocket expenditure. ACCESS Health seeks to onboard the services of a Medical Specialist to provide advisory and capacity support to the
implementation of the scheme.

The position will be based in SACHIS, the State Agency for Comprehensive Health and Integrated Services, Government of Uttar Pradesh.

KEY RESPONSIBILITIES
Medical Adjudication and Case Review

• Review and provide medical opinions on claims flagged through fraud analytics, SAFU/NAFU mechanisms, and other audit processes.
• Support review of disputed, rejected, escalated, and exceptional PM-JAY claims requiring medical assessment.
• Assist SACHIS in reviewing cases placed before grievance redressal and review committees.
• Provide technical inputs on suspected cases of forgery, manipulation, unnecessary procedures, and other provider malpractices.

Audits and Quality Assurance

• Support medical audits, desk reviews, mortality audits, and facility assessments under PM-JAY.
• Assist in identifying patterns of inappropriate utilization, coding errors, upcoding, package misuse, and quality concerns.
• Participate in field audits and provider assessments as required.
• Support the development and implementation of quality assurance processes and audit protocols.

Provider Network Strengthening

• Support provider engagement and capacity building on PM-JAY guidelines, package protocols, documentation standards, and claims processes.
• Assist in improving provider compliance and quality of care delivery.
• Support initiatives to strengthen provider performance monitoring and quality improvement.

Program Support

• Analyse medical and provider performance data to generate operational insights and recommendations.
• Develop reports, briefing notes, presentations, and technical documentation as required.
• Support other PM-JAY implementation activities and special projects assigned by SACHIS and ACCESS Health.

QUALIFICATIONS, EXPERIENCE, AND COMPETENCIES:
Qualifications

• A medical graduate (MBBS) from a recognized university in India, along with registration for clinical practice with the relevant authority in India.
• Preference will be given to candidates with postgraduate qualifications in Public Health, Hospital Administration, Healthcare Management, Community Medicine, or related disciplines.

Experience

• 2–5 years of relevant experience in clinical practice, health insurance, medical audits, claims adjudication, hospital quality, public health programs, or healthcare operations.
• Experience with PM-JAY, health insurance schemes, utilization review, or hospital administration will be an advantage.
• Fresh postgraduates with a strong interest in health systems and health insurance may also be considered.

• Skills and Competencies
  
• Passionate about health systems and looking to create an impact
• Adheres to global standards of professionalism and end excellence
• Is a team player/ believes in a cohesive working environment of growth.
• Good listening skills and open to new ideas/flexibility/adaptability
• In-depth understanding of the hospital’s processes, policies, and procedures will be desirable, along with the ability to verify medical and billing-related documents for further claim processing, as well as from a fraud perspective
• Good spoken and written communication skills, including the ability to prepare clear and concise reports, will be preferred.
• Well-versed in windows MS Office.
• Training skills would be an added advantage
• Willing to travel to districts for field audits supporting SACHIS.

NATURE OF EMPLOYMENT:
The selected candidate shall be offered a fixed-term contract for one-year (renewable)

REPORTING TO:
Global Director Programs