Clover is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans.
Director – Fraud Investigations
Location
United States
Posted
1 day ago
Salary
$150K - $240K / year
Seniority
Lead
Job Description
Director – Fraud Investigations
Clover Health
• 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.
Job Requirements
- 7+ years of experience in healthcare fraud investigations, program integrity, or SIU operations, with meaningful time spent at a Medicare Advantage or managed care plan.
- Management experience overseeing at least a segment of SIU work—whether a particular region or market, or a specific category of fraud (e.g., billing/coding fraud, pharmacy fraud, provider credentialing fraud).
- Sophisticated understanding of healthcare fraud schemes and how to investigate them, including how to work with claims data, medical records, and provider documentation to build a factual record.
- Creative, tech-savvy, and genuinely excited about using AI, data analytics, and automation to transform how investigations are conducted.
- Strong knowledge of Medicare Advantage regulatory requirements, CMS program integrity obligations, and the federal fraud and abuse framework, and you know when and how to bring legal questions to counsel.
- Strong writer and communicator who can translate complex investigative facts into clear memos, referral packages, and executive summaries.
- Thrive in a fast-paced, remote-first environment and are comfortable with ambiguity—you are helping shape an evolving function, not inheriting a static playbook.
Benefits
- Financial Well-Being: Our commitment to attracting and retaining top talent begins with a competitive base salary and equity opportunities. Additionally, we offer a performance-based bonus program, 401k matching, and regular compensation reviews to recognize and reward exceptional contributions.
- Physical Well-Being: We prioritize the health and well-being of our employees and their families by providing comprehensive medical, dental, and vision coverage. Your health matters to us, and we invest in ensuring you have access to quality healthcare.
- Mental Well-Being: We understand the importance of mental health in fostering productivity and maintaining work-life balance. To support this, we offer initiatives such as No-Meeting Fridays, monthly company holidays, access to mental health resources, and a generous flexible time-off policy. Additionally, we embrace a remote-first culture that supports collaboration and flexibility, allowing our team members to thrive from any location.
- Professional Development: Developing internal talent is a priority for Clover. We offer learning programs, mentorship, professional development funding, and regular performance feedback and reviews.
- Additional Perks: Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
- Reimbursement for office setup expenses
- Monthly cell phone & internet stipend
- Remote-first culture, enabling collaboration with global teams
- Paid parental leave for all new parents
- And much more!
Related Guides
Related Categories
Related Job Pages
More Director Jobs
• Lead, mentor, coach, train, and transform delivery teams in application development, security, and infrastructure across key standards and best practices. • Define, implement, and evolve roadmaps for standards and practices across IT functional areas. • Attract and retain top talent and build high-performing teams. • Adapt industry methods for best-fit application at Empower. • Execute Systems strategy and capability roadmaps through department managers and staff. • Deliver work through subordinate managers and ensure projects are completed on time and within predefined requirements and budgets. • Serve as a primary resource to business senior management and operational senior management on current and future Systems Practices and Standards initiatives and resources. • Ensure the creation of policies, procedures, standards, centers of excellence, trainings, enforcement capabilities, and processes to support the ongoing application development enterprise Agile evolution, including SAFe, Scrum, and Lean practices and methodologies. • Collaborate on the evaluation, selection, and implementation of major systems and conversions from existing systems, including identifying technology direction that enables the business to achieve goals more effectively. • Set, develop, and manage applications as applicable to a strategic plan. • Provide direction to ensure efficient and effective area services. • Collaborate with other IT disciplines to ensure changes to the company’s IT environment are implemented at an appropriate level of quality, cost, and architectural consistency. • Ensure monthly alignment with the annual budget through oversight of financial activities. • Provide oversight of adherence to IT internal policies and procedures. • Develop and monitor budgets for departments or work units, including responsibility for budget aspects across multiple work units. • Coach and develop staff to maximize individual performance, build future organizational leadership, enhance teamwork, and strengthen support of the organization’s values, tactics, and strategies. • Estimate staffing needs, create schedules, and assign projects and work for the work functions or departments. • Perform other duties as assigned.
Consultant Relations Director
Included HealthAccess. Answers. Advocacy. We're raising the standard of healthcare for everyone.
• The Consultant Strategy & Relations (CSR) Director will play a key role in strengthening Included Health’s relationships with the broker and consulting community and increasing market preference for our solutions. • This role will be responsible for developing and expanding relationships with influential consultants across national and regional firms in the territory. • The ideal candidate will bring existing relationships and credibility within the consultant ecosystem and be able to leverage those connections to increase awareness and advocacy for Included Health. • The role partners closely with Sales and Client Success to support pipeline development, active sales opportunities, and strategic renewals, while also serving as a key conduit for consultant insights that help shape our market positioning and improve win rates. • Build and maintain trusted relationships with influential consultants across assigned territories and firms. • Proactively expand networks by developing new relationships with senior consultants and industry leaders. • Serve as a primary relationship manager for consulting partners, including establishing partnership agreements with national consulting firms. • Partner with Sales Regional Vice Presidents (RVPs) on coordinated territory strategies that leverage consultant relationships. • Identify priority consultants connected to key prospects and facilitate introductions to drive opportunity development. • Support active opportunities by providing insights on consultant dynamics, positioning, and messaging that can improve win rate. • Articulate Included Health’s value proposition and differentiated capabilities with consultant and broker partners. • Educate the consultant community on Included Health’s products, solutions, and strategic vision, including exclusive previews prior to launching new products. • Facilitate meetings and engagements with consultants to deepen understanding of Included Health’s offerings, and ultimately strengthen market positioning. • Partner with Sales and Marketing to deliver targeted messaging and consultant awareness initiatives. • Partner with Client Success teams on strategic accounts where consultant relationships are critical to renewals or upsell opportunities. • Serve as a strategic advisor on consultant engagement strategies for priority clients. • Help proactively address consultant concerns and influence outcomes in complex renewals or audits. • Monitor consultant perspectives, industry trends, and emerging priorities across broker and consulting firms. • Share actionable insights with Sales, Client Success, and cross-functional partners to inform strategy and market positioning. • Capture and analyze feedback from consultants to inform messaging, product packaging, and future roadmap considerations.
Director of Enrollment
Government Executive Media Group LLCGovExec’s data and insights set the standard for depth, accuracy, and impact for government leaders and contractors. As the market-leading information and intent-based marketing platform, for over fifty years GovExec has empowered the government ecosystem to engage and support government leaders as they work to achieve their missions across federal, defense, and state and local agencies.
Role Description Professional Development Academy (PDA) is seeking a high-performing Director of Enrollment to help lead our customer acquisition and revenue growth targets. In this role, you will be responsible for maximizing sales potential in predefined territories by engaging prospects to build awareness of Academy products and services and converting prospects to sales. Additionally, you will sustain and enhance customer relations with existing and prior customers to drive rebooking of Academy participants. The Director of Enrollment is a seasoned expert who understands the market landscape, our products and services, talk-tracks and demos for prospect engagement, and efficiently maintains daily outbound call volumes and contract close rates, all of which are actively reported as part of the performance management system. The Director of Enrollment is also someone who is self-directed when it comes to building and executing marketing campaigns, follow-up plans, and reporting via succinct dashboards that illustrate TAM, progress toward goals, and effective rates of engagement. Responsibilities - Proactively engage to learn markets, prospects, and outreach tactics - Establish goals and objectives on a rolling basis - Well prepared for each day’s activities relative to other directors and deputies of enrollment - Achieve business success factors, including daily call volumes and weekly enrollment targets - Lead multiple marketing campaigns and outreach strategies simultaneously - Maintain clear (and complete) records of all outreach via CRM - Present dashboard reports of success factors weekly Qualifications - Business degree preferred or equivalent - Preferred five+ years of experience as a successful sales leader, ideally with SLED experience - Committed to continuous personal and professional improvement (especially from feedback) - Proven ability to drive the sales process from prospect to customer and share best practices - Desire to establish business relationships with a focus on leadership development - Strong business savvy and political intuition - Perpetual optimism and desire to get better and better - Self-directed with a strong sense of team collaboration - Proficient with MS-Office applications and databases - Very strong communication skills - Exceptional customer services skills Benefits - Medical, dental, and vision insurance plans - 401(k) retirement plan with company match - Open time off policy - Twelve weeks paid parental leave - Supportive, collaborative teams - Unique opportunity to help government officials from a private sector company - Expansive learning and development opportunities Compensation The compensation range for this role is $60,000 to $82,000, including commission potential. Commitment to Shared Values - Soul of Entrepreneurship - Culture of Inclusion - Force of Ideas - Spirit of Generosity
• Lead the day-to-day management of the patient support program(s) to ensure coordinated access to Neurotech’s Encapsulated Cell Technology. • Provide strategic oversight and management of third-party vendors to ensure service level agreement adherence, quality, consistency, and efficiency in service delivery. • Lead the ongoing evaluation and refinement of the patient support program strategy aligning the efforts of the broad cross-functional team to facilitate high-impact interactions with targeted stakeholders. • Partner with commercial colleagues in the development of market research and analytical projects. • Implement initiatives that maintain a detailed understanding of key stakeholder needs with a long-range approach to brand positioning. • Collaborate with the Trade, Payer and Reimbursement Directors to ensure the coordination and alignment between Patient Support. • Closely monitor competitive activities and stakeholder experience to develop and implement strategies to proactively meet competitive threats. • Create, monitor, and report on all relevant metrics of commercial initiatives. • Foster a team culture of engagement, accountability, collaboration, innovation, sense of urgency to serve patient needs and achieving Neurotech corporate vision. • Complete ad-hoc projects and responsibilities as requested and assigned.



