[Hiring] Director, AI-Enabled Fraud Prevention & Investigations @Clover Health

Role Description

Clover Health is investing in our fraud detection and investigation capabilities and is seeking a Director, AI-Enabled Fraud Prevention & Investigations to join our Legal department as a senior individual contributor. This hybrid role combines:

• Managing hands-on investigations of potential provider fraud
• Building AI-powered tools and processes to make investigations more efficient and help catch potential future fraud earlier

You will develop and pilot new AI-enabled investigatory processes for Clover’s Medicare Advantage business, and own resulting investigations, in collaboration with Clover’s Special Investigations Unit (SIU) and other stakeholders.

This is a non-attorney role. You will work hand-in-hand with Clover’s lawyers and SIU to ensure that new investigatory processes you develop, and the resulting investigations, comply with Clover policies and regulatory requirements. Success in this role requires someone sharp, creative, and technically hands-on—someone who does not just use existing analytics tools but builds their own.

As a Director, AI-Enabled Fraud Prevention & Investigations, you will:

• Build Your Own Investigative Tooling: Use AI to write the queries, scripts, and prompts that turn millions of claim lines and/or medical record data into a prioritized list of leads. Prototype detection logic yourself rather than waiting on a roadmap, and hand off what works to data science and engineering to productionize.
• Investigate Potential Fraud End-to-End With AI in the Loop: Own a portfolio of fraud investigations sourced using the tooling you develop, in collaboration with Clover’s SIU. Develop investigative plans, gather and analyze evidence (including claims data and medical records), and reach well-supported conclusions.
• Build Defensible Documentation: Develop case files and memos that are factually complete, well-organized, and prepared with the evidentiary and procedural standards necessary for downstream enforcement, recoveries, or provider actions.
• Collaborate Across Functions: Work with Clover's clinical, compliance, claims, payment integrity, provider relations, revenue operations, and SIU teams to gather information, validate findings, and translate investigative outcomes into operational improvements, provider education, and member impact.
• Communicate Findings Clearly: Prepare concise written reports and oral briefings that translate complex investigative facts into clear narratives for senior leadership and other stakeholders.

Success in this role looks like:

• In your first 90 days: You have embedded yourself as a trusted partner to both the Legal department and Clover’s SIU. You have built working relationships with key stakeholders across Clover's clinical, compliance, claims, payment integrity, revenue operations, and legal teams, and you have begun working through your initial portfolio of fraud investigations and ad hoc referrals.
• By 6 months: You are independently managing a steady caseload of fraud investigations with consistently high-quality work product, in collaboration with SIU. You have a clear working rhythm with Legal and SIU, and you have built at least one working tool — a script, a notebook, a dashboard, a prompt.
• By 12 months: You have a track record of strong investigations, successful recoveries and/or referrals, and effective cross-functional collaboration. Senior leaders across Clover view you as a trusted person to call when they have a hunch that something doesn't look right and want it examined.

Qualifications

• Experience in healthcare fraud investigations, program integrity, or SIU operations, ideally within Medicare Advantage or managed care.
• Understanding of healthcare fraud schemes and knowledge of how to use claims data, medical records, and provider documentation to build a defensible factual record.
• Ability to use LLMs to write SQL, Python, etc., to interrogate large claims and/or medical record datasets, automate investigative work, and prototype your own solutions.
• Strong writing and communication skills to turn complex investigative findings into clear memos, referrals, and executive summaries.

Requirements

• Demonstrated ability to build, ship, and showcase solutions that work.
• Comfortable building in a fast-moving, ambiguous environment.

Benefits

• Financial Well-Being: Competitive base salary and equity opportunities, performance-based bonus program, 401k matching, and regular compensation reviews.
• Physical Well-Being: Comprehensive medical, dental, and vision coverage.
• Mental Well-Being: Initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy.
• Professional Development: Learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
• Additional Perks: Employee Stock Purchase Plan (ESPP), reimbursement for office setup expenses, monthly cell phone & internet stipend, remote-first culture, paid parental leave for all new parents.