Director, AI-Enabled Fraud Prevention & Investigations

Responsibilities

• Own Investigative Tooling: Use AI to write the queries, scripts, and prompts that turn millions of claim lines and/or medical record data into a prioritized list of leads. Prototype detection logic yourself rather than waiting on a roadmap, and hand off what works to data science and engineering to productionize. We…
• Build Defensible Documentation
• Develop case files and memos that are factually complete, well-organized, and prepared with the evidentiary and procedural standards necessary for downstream enforcement, recoveries, or provider actions.
• 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.

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