Director, Fraud Investigations

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.

As a Director, Fraud Investigations, you will:

• 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.

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 the 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. Your referral packages are well-received by enforcement partners. You have a clear working rhythm with Legal that makes it easy to surface legal questions and incorporate counsel's input, and you have helped deploy or actively use at least one new technology or analytics tool to make your investigations more effective.
• By 12 months, you have a track record of strong investigations, successful recoveries within your portfolio, and effective cross-functional collaboration. Senior leaders across Clover view you as the 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:

• You have 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.
• 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 have 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.
• You are 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.
• 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.
• You 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.
  

  Bonus points if:

  • You hold a J.D. or have legal training, though a law degree is not required for this role.
  • You have worked within or alongside the Legal department at a health plan, supporting SIU or compliance functions.
  • You have prior experience at a Medicare Advantage plan specifically (as opposed to commercial or Medicaid only).
  • You hold industry certifications such as CFE (Certified Fraud Examiner), AHFI (Accredited Health Care Fraud Investigator), or CHC (Certified in Healthcare Compliance).
  • 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.

Benefits Overview:

• 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!

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.

We always put our members first, and our success as a team is measured by the quality of life of the people we serve. 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.

From Clover’s inception, Diversity & Inclusion have always been key to our success. 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. 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. All of our employee’s points of view are key to our success, and inclusion is everyone's responsibility.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are anE-Verify company.

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