Subject Matter Expert - Medical Fraud, Waste and Abuse
Subject Matter Expert - Medical Fraud, Waste and Abuse
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Salary Not Disclosed
1 Vacancy
Job Description
Shift is the leading AI platform for insurance. Shift combines generative agentic and predictive AI to transform underwriting claims and fraud and risk - driving operational efficiency exceptional customer experiences and measurable business impact. Trusted by the worlds leading insurers Shift delivers AI when and where it matters most at scale and with proven results.
Our culture is built on innovation trust and a drive to transform the insurance industry through our SaaS platform. We come from more than 50 different countries and cultures and together we are creating the future of insurance.
We are seeking a medically trained Fraud Waste and Abuse (FWA) Subject Matter Expert to join our growing team in Mexico City. This role is critical to enhancing our fraud detection capabilities in Latin America particularly in Mexico by introducing deep clinical insights into medical claims review. The FWA SME will play a highly operational roleleading the triage of clinical alerts analyzing medical documentation and helping build advanced medically informed fraud scenarios for major health insurers.
This position is ideal for a physician with experience in health insurance medical auditing or fraud investigations who is passionate about leveraging clinical knowledge to fight healthcare fraud and improve system efficiency.
Key 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.
Required Qualifications
- 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.
To support our permanent full time employees at every stage of their careers and lives we provide a competitive total rewards and benefits package. Here are the global benefits wed like to highlight:
- 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)
Additional benefits may be offered by country - ask your recruiter for more information. Intern and Apprentice position are eligible for some of these benefits - ask your recruiter for more details.
At Shift we strive to be a diverse and inclusive workforce. We welcome applications from and hire people who will contribute to the diversity of our companywithout regard to race color religion marital status age national or ethnic origin physical or mental disability medical condition pregnancy genetic information gender identity or expression sexual orientation or other non-merit criteria.
Shift Technology is committed to providing reasonable accommodations for qualified individuals with disabilities in our application and employment process. Should you require accommodation please email and we will work with you to meet your accessibility needs.
Please be aware of scammers and only trust correspondence that comes from emails ending in . We will never do initial outreach to you via Whatsapp/Text/SMS never ask for banking information or personal identification numbers (ex. Social Security Number) as part of our recruitment process.
Shift Technology does not accept unsolicited CVs from recruiters or employment agencies in response to the Shift Technology Careers page or a Shift Technology social media post. Any unsolicited CVs including those submitted directly to hiring managers are deemed to be the property of Shift Technology.
Employment Type
Full Time
