Director, AI-Enabled Fraud Prevention & Investigations

Clover Health

1d•$150,000 - $240,000•Hybrid

About The Position

Clover Health is seeking a Director, AI-Enabled Fraud Prevention & Investigations to join their Legal department as a senior individual contributor. This hybrid role involves managing hands-on investigations of potential provider fraud and building AI-powered tools and processes to enhance efficiency and early detection of potential future fraud. The role will focus on developing and piloting new AI-enabled investigatory processes for Clover’s Medicare Advantage business, owning resulting investigations in collaboration with Clover’s Special Investigations Unit (SIU) and other stakeholders. This is a non-attorney role where the individual will work closely with Clover’s lawyers and SIU to ensure compliance with company policies and regulatory requirements. The ideal candidate is sharp, creative, and technically hands-on, capable of building their own analytical tools, automating repetitive tasks, analyzing datasets, and leveraging LLMs to improve fraud investigation methods.

Requirements

Knowledge of healthcare fraud schemes and investigative experience, ideally within Medicare Advantage or managed care.
Understanding of healthcare fraud schemes and proficiency in using claims data, medical records, and provider documentation to build a factual record.
AI-native with the ability to use LLMs to write SQL, Python, etc., for data interrogation, automation, and prototyping solutions.
Demonstrated ability to build, ship, and showcase working solutions.
Strong communication and writing skills, capable of translating complex findings into clear memos, referrals, and executive summaries.
Comfort building in a fast-moving, ambiguous environment.

Nice To Haves

Experience building tools, detection models, scripts, automations, or AI workflows that have improved manual processes.
Hands-on experience applying AI/ML to fraud, investigations, or compliance.
A J.D., legal training, or experience working alongside Legal, SIU, or compliance at a health plan.
Industry certifications such as CFE, AHFI, or CHC.

Responsibilities

Build AI-enabled investigative tooling, including writing queries, scripts, and prompts to analyze claim lines and medical record data for prioritized leads.
Prototype detection logic independently and collaborate with data science and engineering for productionization.
Own and manage a portfolio of fraud investigations from sourcing to conclusion, in collaboration with Clover’s SIU.
Develop investigative plans, gather and analyze evidence (claims data, medical records), and reach well-supported conclusions.
Utilize LLMs and analytics to expedite investigation components such as unstructured data review, grievance narrative triage, and exposure sizing.
Develop defensible documentation, including case files and memos, meeting evidentiary and procedural standards for downstream actions.
Collaborate with clinical, compliance, claims, payment integrity, provider relations, revenue operations, and SIU teams to gather information, validate findings, and drive operational improvements.
Communicate complex investigative findings clearly through concise written reports and oral briefings for senior leadership and stakeholders.