Director, Fraud Investigations

Clover Health

2d•$150,000 - $240,000•Remote

About The Position

Clover Health’s legal team is a group of proactive business partners whose mission is to empower the organization to innovate and achieve its goals within a dynamic and fluid regulatory environment. We are committed to supporting continued excellence for our customers while building a sustainable future for the organization. We believe integrity, collaboration, and sustainability ensures Clover Health exceeds its objectives, while upholding the highest standards of legal and ethical responsibility. Clover Health is investing in our fraud detection and investigation capabilities, and we are looking for a Director, Fraud Investigations to join our Legal department as a senior individual contributor. This role is an extension of our Special Investigations Unit (SIU) that sits within Legal—you will spend your days investigating suspected fraud against Clover's Medicare Advantage business and ensuring that those investigations are coordinated, well-documented, and supported by the right legal advice from the Legal department. Reporting to Clover's Legal department, you will own a portfolio of fraud investigations end-to-end. Those investigations will originate from SIU's standard intake processes as well as other channels. In every case, you will dig in, gather and analyze the facts, partner with stakeholders across the company, and reach a defensible conclusion. This is a non-attorney role. You will not be providing legal advice yourself; instead, you will work hand-in-hand with Clover's lawyers to make sure your investigations have the legal guidance they need, and that referrals, recoveries, and provider actions are appropriately reviewed by counsel. You are sharp, creative, and technology-forward, and you see AI and data analytics not as threats to the craft of investigation but as the most exciting tools to enter the field in a generation.

Requirements

7+ years of experience in healthcare fraud investigations, program integrity, or SIU operations, with meaningful time spent at a Medicare Advantage or managed care plan.
Management experience overseeing at least a segment of SIU work—whether a particular region or market, or a specific category of fraud (e.g., billing/coding fraud, pharmacy fraud, provider credentialing fraud).
A sophisticated understanding of healthcare fraud schemes and how to investigate them, including how to work with claims data, medical records, and provider documentation to build a factual record.
Creative, tech-savvy, and genuinely excited about using AI, data analytics, and automation to transform how investigations are conducted. You want to be at the forefront of modernizing fraud detection work.
Strong knowledge of Medicare Advantage regulatory requirements, CMS program integrity obligations, and the federal fraud and abuse framework, and you know when and how to bring legal questions to counsel.
A strong writer and communicator who can translate complex investigative facts into clear memos, referral packages, and executive summaries.
Thrive in a fast-paced, remote-first environment and are comfortable with ambiguity—you are helping shape an evolving function, not inheriting a static playbook.

Nice To Haves

Hold a J.D. or have legal training, though a law degree is not required for this role.
Worked within or alongside the Legal department at a health plan, supporting SIU or compliance functions.
Prior experience at a Medicare Advantage plan specifically (as opposed to commercial or Medicaid only).
Hold industry certifications such as CFE (Certified Fraud Examiner), AHFI (Accredited Health Care Fraud Investigator), or CHC (Certified in Healthcare Compliance).
Experience with New Jersey's regulatory and provider environment.
Hands-on experience implementing or using AI/ML tools in an investigative or compliance setting.
Experience with government enforcement—whether at a U.S. Attorney's Office, HHS-OIG, a state AG's office, or a Medicaid Fraud Control Unit.

Responsibilities

Investigate Suspected Fraud End-to-End: Own a portfolio of fraud investigations from intake through resolution. Develop investigative plans, gather and analyze evidence (including claims data, medical records, and provider documentation), interview witnesses where appropriate, and reach well-supported conclusions.
Handle Ad Hoc Internal Referrals: Take on investigations triggered by referrals from senior leaders and other internal stakeholders—e.g., a suspected provider outlier or a tip about potentially anomalous behavior—and provide a clear, factual assessment of whether something is amiss.
Coordinate Legal Support for Your Investigations: Work closely with Clover's attorneys to ensure each investigation has the legal guidance it needs. Identify legal questions early, route them to the right lawyer, and incorporate counsel's input into investigative strategy, documentation, referrals, and provider actions.
Build Defensible Documentation: Develop case files, memos, and referral packages that are factually complete, well-organized, and prepared with the evidentiary and procedural standards necessary for downstream enforcement, recoveries, or provider actions—working with Legal to confirm those standards are met.
Support Regulatory and Law Enforcement Referrals: Prepare referral packages for CMS, the MEDIC contractor, HHS-OIG, state fraud units, and law enforcement agencies, and coordinate with Legal on the form and substance of each referral. Track referral outcomes and help maintain relationships with enforcement partners.
Leverage Technology and AI: Partner with the VP of SIU and Clover's data science and engineering teams to evaluate, deploy, and refine AI-driven detection tools, predictive analytics, and data visualization platforms. Be a hands-on user and champion of technology in your own investigative work.
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.