Healthcare fraud drains billions from the medical system every year, and staying ahead of sophisticated bad actors demands far more than static rules and standard dashboards. At Clover Health, we are rethinking investigative methodology from the ground up by weaving artificial intelligence directly into the fabric of our detection efforts. We are looking for a sharp, proactive Director of AI-Enabled Fraud Prevention and Investigations to join our Legal department as a senior individual contributor. If you love dissecting complex healthcare data, writing your own scripts when standard reports fall short, and running end-to-end fraud cases yourself, this fully remote worldwide role offers a unique opportunity to build something truly impactful.

Role Overview

This is a non-attorney position that bridges high-stakes investigative curiosity and hands-on technical problem solving. Rather than merely triaging existing alerts, you will actively conduct provider fraud investigations while engineering new AI-powered systems to identify deceptive patterns much faster. Working in close partnership with Clover's Special Investigations Unit and legal counsel, you will develop compliant, cutting-edge workflows designed to safeguard our Medicare Advantage plans and protect vital healthcare resources.

Key Responsibilities

Your work will balance technical creation with concrete investigative execution. Core responsibilities include

Leading rigorous investigations into suspected healthcare provider fraud, waste, and abuse from initial detection through resolution.
Designing, prototyping, and deploying tailored AI and automation tools to catch emerging fraud schemes before they scale.
Collaborating with in-house attorneys and compliance teams to ensure all investigative workflows satisfy strict regulatory standards.
Extracting, cleaning, and analyzing messy healthcare claims datasets using custom code and exploratory data analysis.
Transforming lessons learned from closed cases into automated detection heuristics and scalable prevention strategies.

Requirements

Success in this seat requires someone with strong investigative instincts and genuine hands-on technical fluency. Ideal qualifications include

Extensive background conducting complex healthcare fraud inquiries, with deep familiarity in Medicare Advantage or commercial payer data.
Demonstrated proficiency in Python, SQL, or comparable languages to build automation scripts and query high-volume relational databases.
Direct experience implementing machine learning, natural language processing, or modern AI tools to solve real investigative challenges.
Working knowledge of Special Investigations Unit best practices and healthcare regulatory landscapes.
An entrepreneurial mindset as a senior individual contributor who takes initiative without waiting for step-by-step instructions.

What You Will Gain

Taking on this role means joining a forward-looking company that values builder mentalities. You can look forward to

True autonomy with a fully remote, worldwide work setup that lets you produce your best work from anywhere.
The chance to build proprietary AI-driven investigative tooling from scratch without having to fight legacy constraints.
Meaningful collaboration with seasoned legal experts and data specialists dedicated to improving healthcare transparency.
The satisfaction of driving measurable outcomes that safeguard patients and prevent systemic abuse.