Director, AI-Enabled Fraud Prevention & Investigations

About the role

Clover Health is seeking a Director, AI-Enabled Fraud Prevention & Investigations to join the Legal department as a senior individual contributor. This role involves managing hands-on investigations of potential provider fraud while building AI-powered tools and processes to enhance investigative efficiency. You will develop and pilot new AI-enabled investigatory processes for the Medicare Advantage business and collaborate with the Special Investigations Unit to ensure compliance and regulatory standards.

Responsibilities

• Build AI-driven investigative tooling including queries, scripts, and prompts to prioritize leads from claims and medical record data.
• Own a portfolio of fraud investigations, developing plans and analyzing evidence to reach well-supported conclusions.
• Develop defensible case files and memos that meet evidentiary and procedural standards for downstream enforcement.
• Collaborate with clinical, compliance, claims, payment integrity, and provider relations teams to validate findings and drive operational improvements.
• Prepare clear written reports and oral briefings to translate complex investigative facts for senior leadership.

Required skills

• Healthcare fraud investigations
• Program integrity
• SIU operations
• Medicare Advantage
• LLMs
• SQL
• Python
• Data analysis

Nice to have

• Internal tool development
• AI/ML application
• Legal training

Qualifications

• Experience in healthcare fraud investigations, program integrity, or SIU operations
• Demonstrated ability to build and ship technical solutions using LLMs

Certifications

• CFE
• AHFI
• CHC

Benefits

• Health insurance
• Dental coverage
• Vision coverage
• 401k matching
• Performance-based bonus
• Flexible time-off policy
• Paid parental leave
• Office setup reimbursement
• Cell phone and internet stipend
• Employee Stock Purchase Plan

About the Company

Clover Health is reinventing health insurance by combining data with human empathy to keep members healthier. They have created custom software and analytics to empower clinical staff to provide personalized care.