Director, Fraud Investigations

About Clover Health: Clover Health is reinventing health insurance by combining the power of advanced data science with deep human empathy to keep our members healthier. Recognizing that the traditional healthcare infrastructure possesses systemic gaps, we build custom software and analytics suites to empower our clinical teams to intervene and provide personalized, proactive care to the populations who need it most. We place our members first, evaluating our team collective success by the quality of life of the individuals we serve. Driven by a mission to fix a fractured market, we bring together diverse specialists to solve the most complicated healthcare and operational problems in the world.

Position Overview

We are seeking a highly analytical, investigative, and tech-forward Director, Fraud Investigations to join our centralized Special Investigations Unit (SIU) within the Legal department under a permanent, full-time remote layout open across the United States. Functioning as a senior individual contributor, you will take end-to-end commercial ownership of a diverse portfolio of fraud investigations originating across our core Medicare Advantage business channels. Shifting completely away from routine staff recruiting, entry-level payroll bookkeeping, or simple non-regulated file review, you will operate as a principal fact-finding authority. This non-attorney position requires a program integrity leader with 7+ years of experience who drives healthcare investigations fluidly natively using Legal Consultant and data audit frameworks, evaluates complex claims architectures and provider medical records cleanly, routes key regulatory queries to corporate counsel systematically, and partners with internal data science cells to deploy AI-powered anomaly detection tools across live corporate systems.

Key Responsibilities

• End-to-End Fraud Investigation Governance: Own and execute a complex caseload of fraud investigations from initial intake through final resolution—developing thorough investigative plans and gathering clinical evidence natively utilizing Legal Consultant and program integrity standards.
• Factual Evidence Analysis: Audit, reconstruct, and interpret high-volume healthcare claims data, provider medical records, billing/coding histories, and credentialing files to construct unassailable factual records.
• Internal & Executive Referral Triage: Lead deep-dive investigations triggered by ad-hoc referrals from senior corporate leadership or internal audit teams, delivering high-clarity assessments regarding potentially anomalous provider behaviors.
• Cross-Functional Legal Synchronization: Partner hand-in-hand with Clover internal lawyers, routing strategic legal questions early and incorporating counsel input into investigative strategy, recovery actions, and external provider sanctions.
• Defensible Documentation Engineering: Compile complete case memos, executive files, and comprehensive referral packages that fulfill strict evidentiary and procedural standards required for downstream enforcement or financial recoveries.
• Regulatory and Law Enforcement Delivery: Coordinate and prepare clean, legally sound referral packages for external enforcement entities, including CMS, the MEDIC contractor, HHS-OIG, and state Medicaid Fraud Control Units.
• AI-Native Fraud Optimization: Partner directly with the VP of SIU and internal data science cells to pilot, evaluate, and embed machine learning tools, predictive analytics, and data visualization software to modernize our fraud detection footprint.

Required Skills & Qualifications

• A minimum of 7+ years of professional history operating in healthcare fraud investigations, corporate compliance, program integrity, or SIU operational roles.
• Mandatory Managed Care Depth: Meaningful, documented career history spent directly inside a Medicare Advantage or managed care plan environment.
• Proven managerial or programmatic experience supervising a segment of SIU workflows (such as a regional market, provider network pool, or a specific fraud vertical like billing/coding or pharmacy fraud).
• Sophisticated understanding of healthcare fraud schemes, with verified experience parsing claims data and interviewing witnesses to establish clean records.
• Outstanding written communication skills, with an established ability to translate complex, abstract investigative facts into crisp narratives, executive summaries, and referral briefs.
• Location Context: Position operates under remote guidelines open to qualified compliance professionals residing permanently within the USA .

Preferred Strategic Indicators (Nice to Have)

• Possess a formal Juris Doctor (J.D.) degree or structured paralegal and legal training (note: a law degree is highly valued but not a rigid requirement).
• Prior experience collaborating directly alongside or inside the Legal department of a commercial health plan to support compliance functions.
• Active industry-recognized certifications, such as a CFE (Certified Fraud Examiner), AHFI (Accredited Health Care Fraud Investigator), or CHC (Certified in Healthcare Compliance) .
• Hands-on background deploying or configuring machine learning (AI/ML) models or visual graph databases within an investigative or compliance landscape.

What We Offer

• Competitive Executive Compensation Matrix: An attractive base salary range of $133,000 – $177,000 USD calibrated to individual background and geographic location, supplemented by performance bonuses and equity opportunities.
• 100% remote-first operational freedom, empowering you to drive healthcare integrity from your domestic home office.
• Employee Stock Purchase Plan (ESPP): Discounted equity pathways allowing you to participate directly in our financial growth.
• Comprehensive health assurance packages, providing top-tier medical, dental, and vision insurance for you and your family.
• Mental Well-Being Initiatives: Full access to professional mental health resources, a flexible time-off framework, monthly company holidays, and dedicated "No-Meeting Fridays" to ensure uninterrupted deep work.
• Generous paid parental leave benefits for all new parents, full home office hardware setup reimbursements, and a monthly internet/cell phone tech stipend.