Director – Fraud Investigations

🕒 June 24

🇺🇸 United States – Remote

💵 $150k - $240k / year

⏰ Full Time

🔴 Lead

👔 Director

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🏥 Healthcare

🛡️ Insurance

🤖 Artificial Intelligence

Healthcare • Insurance • Artificial Intelligence

Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.

📋 Description

• 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.

🎯 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). • 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. • 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. • 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.

🏖️ Benefits

• Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions. • Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare. • Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location. • Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews. • Additional Perks: Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities • Reimbursement for office setup expenses • Monthly cell phone & internet stipend • Remote-first culture, enabling collaboration with global teams • Paid parental leave for all new parents • And much more!