Sr. Director, Clinical Operations
C
Cohere HealthHealthcare technology
Location: Remote in India preferably in southern states., Shift schedules for real-time collaboration with US clinical teams; flexibility for extended hours during client launches, audits, or client requirements.Full-TimeDirector
Salary not disclosed
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Job Details
- Experience
- Minimum 12–15 years of progressive experience in clinical operations, utilization management, and/or healthcare operations, with at least 5 years in a senior leadership role.
- Required Skills
- Google WorkspaceHIPAA
Requirements
- Bachelor's degree in Nursing (BSN).
- Active US Registered Nurse license (NCLEX-RN).
- Minimum 12–15 years of progressive experience in clinical operations, utilization management, and/or healthcare operations.
- At least 5 years in a senior leadership role.
- Experience with prospective, concurrent, and retrospective utilization review or utilization management.
- Experience establishing and managing clinical operations in a GCC, GIC, BPO, or offshore environment, preferably serving US healthcare payer clients.
- Expertise in US healthcare delivery systems, payer operations, and the prior authorization lifecycle across Commercial, Medicare, and Medicaid.
- Hands-on experience with MCG Care Guidelines, InterQual, and/or equivalent evidence-based criteria.
- Experience managing NCLEX-certified RN teams in India or other offshore locations.
- Experience with CMS regulatory requirements, HIPAA, and HITRUST compliance frameworks.
- Experience managing 50+ clinical professionals, including hiring, training, performance management, and workforce planning.
- Ability to lead cross-border, cross-functional teams across US and India time zones.
Responsibilities
- Establish and operationalize the clinical RN review function at the Hyderabad GIC, including infrastructure, workflows, staffing models, and technology enablement.
- Design and implement a scalable operating model for clinical prior authorization reviews across delegated specialties.
- Develop and maintain SOPs, work instructions, clinical review protocols, and decision-support frameworks aligned with US clinical standards.
- Recruit, onboard, train, mentor, and develop RN Supervisors, Team Leads, and RN Reviewers.
- Oversee daily clinical review operations, including medical necessity reviews, clinical documentation assessment, and guideline application.
- Manage case volumes, workload distribution, staffing adequacy, and turnaround times across specialties and payer client portfolios.
- Establish clinical quality assurance processes, including inter-rater reliability assessments, audit protocols, and quality scorecards.
- Ensure clinical operations comply with HIPAA, HITRUST, CMS, NCQA, and applicable state regulatory requirements.
- Collaborate with US clinical, operational, product, compliance, quality, and health plan teams on handoffs, governance, and escalations.
- Provide operational performance reports, clinical quality dashboards, and workforce analytics to US leadership.
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