Director, AI-Enabled Fraud Prevention & Investigations
Core
Director leading hands-on AI-enabled investigations of provider fraud for Clover's Medicare Advantage business, building custom tooling to detect and analyze claims/medical data.
Role type
Senior IC Director (Fraud Investigations & AI Tooling)
Builds
Custom AI scripts, LLM workflows, and detection logic for fraud investigations
Domain
Healthcare insurance (Medicare Advantage) + Fraud Detection + AI/LLM
Deliverable
production ML models | product features
Required skills
Healthcare fraud investigation experience, AI/LLM prototyping (SQL/Python), claims data analysis, medical record review, defensible documentation, cross-functional collaboration
Preferred skills
Built internal tools/scripts, applied AI/ML to fraud/compliance, legal training or SIU experience, CFE/AHFI/CHC certification
Technologies
LLMs, SQL, Python
Responsibilities
Develop and pilot AI-enabled investigatory processes; own end-to-end fraud investigations using custom tooling; build defensible case files and memos; collaborate with Legal, SIU, and clinical teams; communicate findings to senior leadership
Seniority
Director, Senior IC
