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 inve

Director, AI-Enabled Fraud Prevention & Investigations at Clover Health