Clover Health

Director, Fraud Investigations

Remote - USA · Director · Contract

Sponsorship not specifiedDetected 20 days ago

Machine LearningData AnalysisData ScienceData VisualizationLeadershipCollaborationMentoring

About the role

We believe integrity, collaboration, and sustainability ensures Clover Health exceeds its objectives, while upholding the highest standards of legal and ethical responsibility.
Those investigations will originate from SIU's standard intake processes as well as other channels.
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.

Own a portfolio of fraud investigations from intake through resolution.
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.
Track referral outcomes and help maintain relationships with enforcement partners.

You have 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).
You are creative, tech-savvy, and genuinely excited about using AI, data analytics, and automation to transform how investigations are conducted.
You have 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.
You are a strong writer and communicator who can translate complex investigative facts into clear memos, referral packages, and executive summaries.
By 6 months, you are independently managing a steady caseload of fraud investigations with consistently high-quality work product.
By 12 months, you have a track record of strong investigations, successful recoveries within your portfolio, and effective cross-functional collaboration.

You hold a J.D. or have legal training, though a law degree is not required for this role.
You have prior experience at a Medicare Advantage plan specifically (as opposed to commercial or Medicaid only).
You have experience with New Jersey's regulatory and provider environment.
You have hands-on experience implementing or using AI/ML tools in an investigative or compliance setting.
You have 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.

Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities.

Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
Reimbursement for office setup expenses
Monthly cell phone & internet stipend
Paid parental leave for all new parents
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.
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.
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.
Develop investigative plans, gather and analyze evidence (including claims data, medical records, and provider documentation), interview witnesses where appropriate, and reach well-supported conclusions.

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.

This listing is sourced directly from Clover Health's careers page and normalized into a canonical job model.