Director, AI-Enabled Fraud Prevention & Investigations

The role

This senior individual contributor role manages hands-on investigations of potential provider fraud and builds AI-powered tools to improve efficiency. You will develop and pilot new AI-enabled investigatory processes for the Medicare Advantage business.

What you will do

• Build investigative tooling using AI to write queries, scripts, and prompts
• Prototype detection logic to hand off to data science and engineering
• Own a portfolio of fraud investigations using developed tooling
• Develop investigative plans and analyze evidence including claims data and medical records
• Use LLMs and analytics to process unstructured data and grievance narratives
• Develop factually complete case files and memos for enforcement or recoveries
• Collaborate with clinical, compliance, claims, and SIU teams
• Prepare written reports and oral briefings for senior leadership

Required qualifications

• Experience in healthcare fraud investigations, program integrity, or SIU operations
• Understanding of healthcare fraud schemes
• Ability to use claims data, medical records, and provider documentation to build a factual record
• Ability to use LLMs to write SQL, Python, etc. to interrogate datasets and automate work
• Strong writing and communication skills

Nice to have

• Built an internal tool, detection model, script, automation, or AI workflow that was used
• Hands-on experience applying AI/ML to fraud, investigations, or compliance
• J.D., legal training, or experience working alongside Legal, SIU, or compliance at a health plan
• Industry certifications such as CFE, AHFI, or CHC

Benefits

• Competitive base salary and equity opportunities
• Performance-based bonus program
• 401k matching
• Regular compensation reviews
• Medical, dental, and vision coverage
• No-Meeting Fridays
• Monthly company holidays
• Access to mental health resources
• Flexible time-off policy
• Learning programs, mentorship, and professional development funding
• Employee Stock Purchase Plan (ESPP)
• Reimbursement for office setup expenses

Before you apply

• Will consider qualified applicants with arrest and conviction records per San Francisco Fair Chance Ordinance
• E-Verify company

About the company

Clover Health is reinventing health insurance by combining the power of data with human empathy. They use custom software and analytics to empower clinical staff to provide personalized care.