Director, AI-Enabled Fraud Prevention & Investigations
New
C
Clover HealthHealth Insurance
Remote - USAFull-TimeDirector
Salary$150,000 — $240,000 USD
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Job Details
- Required Skills
- PythonSQLArtificial IntelligenceData AnalysisCompliance
Requirements
- Experience in healthcare fraud investigations, program integrity, or SIU operations.
- Familiarity with Medicare Advantage or managed care environments.
- Ability to use LLMs to write SQL, Python, or similar to interrogate large datasets.
- Demonstrated ability to build, ship, and showcase functional technical solutions.
- Strong writing and communication skills for technical and executive reporting.
- Knowledge of how to build a defensible factual record using claims data and medical records.
- Experience working in a fast-moving, ambiguous environment.
- Proficiency with healthcare fraud schemes.
- Preferred: Hands-on experience applying AI/ML to fraud or compliance.
- Preferred: JD, legal training, or experience working with legal/compliance teams.
- Preferred: Industry certifications such as CFE, AHFI, or CHC.
Responsibilities
- Build custom investigative tooling including queries, scripts, and prompts to prioritize leads from large datasets.
- Prototype detection logic and collaborate with data science and engineering for productionization.
- Conduct end-to-end fraud investigations, including developing plans and analyzing claims/medical record evidence.
- Utilize LLMs and analytics to automate unstructured data reading, grievance triaging, and exposure sizing.
- Draft defensible case files and memos that meet evidentiary standards for enforcement and recovery.
- Collaborate with clinical, compliance, claims, and payment integrity teams to validate findings and improve operations.
- Prepare clear investigative narratives and reports for senior leadership.
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