Subject Matter Expert - Medical Fraud, Waste and Abuse

Summary

Join Shift Technology, a leading AI platform for insurance, as a medically trained Fraud, Waste, and Abuse (FWA) Subject Matter Expert in Mexico City. This crucial role focuses on enhancing fraud detection capabilities in Latin America by leveraging deep clinical insights into medical claims review. You will lead the triage of clinical alerts, analyze medical documentation, and build advanced fraud scenarios for major health insurers. The ideal candidate is a physician with health insurance, medical auditing, or fraud investigation experience and a passion for fighting healthcare fraud. This position involves close collaboration with various teams and requires strong analytical skills and fluency in Spanish and English. Shift offers a competitive total rewards and benefits package, including flexible work options, competitive salary, equity, and generous PTO.

Requirements

• Medical degree (MD) with full credentials to practice in Mexico
• Minimum of 5 years of clinical experience, with demonstrated expertise in interpreting and evaluating complex medical documents
• Proven experience in the Mexican health insurance industry, FWA Handler, or in a similar function involving claim review and fraud detection
• In-depth knowledge of the Mexican healthcare system, including provider behaviors, care protocols, and payer policies
• Strong analytical mindset and attention to detail in reviewing clinical documentation and identifying anomalies
• Fluency in Spanish and English (spoken and written)
• High integrity, professionalism, and comfort working with confidential information

Responsibilities

• Act as the main contact point for any medical related inquiry by Shift Customers
• Provide feedback to the product and delivery teams on local medical insights for improving our products or results with current customers
• Conduct daily clinical triage of fraud alerts by reviewing medical claims and documentation, identifying clinical inconsistencies, and prioritizing high-value cases for client fraud investigation teams
• Identify inconsistencies, upcoding, overtreatment, or suspicious provider patterns through expert review of diagnoses, procedures, and care plans
• Collaborate with Customer Success and Data Science teams to design and validate medically grounded fraud detection scenarios
• Define and refine clinical variables to improve machine learning models and AI performance
• Translate real-world medical practices into actionable insights for the development of scalable anti-fraud scenarios for fraud detection
• Participate in internal discussions and client-facing workshops, representing medical and clinical perspectives
• Provide ongoing support to LATAM markets, acting as a key operational and consultative partner to clients’ fraud teams

Benefits

• Flexible remote and hybrid working options
• Competitive Salary and a variable component tied to personal and company performance
• Company equity
• Focus Fridays, a half-day each month to focus on learning and personal growth
• Generous PTO and paid holidays
• Mental health benefits
• 2 MAD Days per year (Make A Difference Days for paid volunteering)