Clover Health - Director, Fraud Investigations
Requirements
• 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.
Responsibilities
• 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.
Benefits
• 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 • 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.
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