Director, Fraud Investigations

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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 in

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