Director, AI-Enabled Fraud Prevention & Investigations

Job 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: (1) managing hands-on investigations of potential provider fraud with (2) 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. That might mean writing a script to automate repetitive work, pulling apart a dataset when a standard report falls short, or working with an LLM until it produces something genuinely useful—all with the goal of finding smarter, more effective ways to investigate potential provider fraud. **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. We expect you to be the person who builds v1. - **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. Use LLMs and analytics to compress the parts of an investigation that have always been slow — reading unstructured data, triaging grievance narratives, and sizing exposure. - **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. **You should get in touch if:** - **Knowledge of healthcare fraud schemes & investigative experience:** You have experience in healthcare fraud investigations, program integrity, or SIU operations, ideally within Medicare Advantage or managed care. You understand healthcare fraud schemes and know how to use claims data, medical records, and provider documentation to build a defensible factual record. - **You are AI-native and enjoy building things using LLMs:** You can use LLMs to write SQL, Python, etc., to interrogate large claims and/or medical record datasets, automate investigative work, and prototype your own solutions rather than waiting for someone else to build them. *We do not expect production-grade engineering or require formal technical training—we value demonstrated ability to build, ship, and showcase solutions that work.* - **Strong communication skills:** You are a strong writer and communicator who can turn complex investigative findings into clear memos, referrals, and executive summaries, and you are comfortable building in a fast-moving, ambiguous environment. **Bonus points if:** - - You have built something people actually use—an internal tool, detection model, script, automation, or AI workflow that made a manual process better. We would rather see something scrappy and useful in production than something polished in a slide. - You have hands-on experience applying AI/ML to fraud, investigations, or compliance. - You have a J.D., legal training, or experience working alongside Legal, SIU, or compliance at a health plan. - You have industry certifications such as CFE, AHFI, or CHC. --- **Benefits Overview**: - **Financial Well-Being**: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions. - **Physical Well-Being**: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare. - **Mental Well-Being**: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. - **Professional Development**: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews. *Additional Perks:* - Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities - Reimbursement for office setup expenses - Monthly cell phone & internet stipend - Remote-first culture, enabling collaboration with global teams - Paid parental leave for all new parents - And much more! --- **About Clover:** We are reinventing health insurance by combining the power of data with human empathy to keep our members healthier. We believe the healthcare system is broken, so we've created custom software and analytics to empower our clinical staff to intervene and provide personalized care to the people who need it most. We always put our members first, and our success as a team is measured by the quality of life of the people we serve. Those who work at Clover are passionate and mission-driven individuals with diverse areas of expertise, working together to solve the most complicated problem in the world: healthcare. From Clover’s inception, Diversity & Inclusion have always been key to our success. We are an Equal Opportunity Employer and our employees are people with different strengths, experiences, perspectives, opinions, and backgrounds, who share a passion for improving people's lives. Diversity not only includes race and gender identity, but also age, disability status, veteran status, sexual orientation, religion and many other parts of one’s identity. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility. --- #LI-REMOTE *Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an*[*E-Verify*](https://e-verify.uscis.gov/esp/media/resourcesContents/E-Verify_Participation_Poster.pdf) *company.* Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc. A reasonable estimate of the base salary range for this role is: $150,000—$240,000 USD