Senior Director, Clinical Operations
C
Cohere HealthHealthcare utilization management
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 of experience in a senior leadership role.
- Experience in utilization review or utilization management, including prospective, concurrent, and retrospective reviews.
- Experience establishing and managing clinical operations in a GCC, GIC, BPO, or offshore environment, preferably for US healthcare payer clients.
- Knowledge of US healthcare delivery systems, payer operations, and prior authorization across Commercial, Medicare, and Medicaid.
- Hands-on experience with MCG Care Guidelines, InterQual, or equivalent evidence-based clinical criteria.
- Experience managing NCLEX-certified RN teams in India or other offshore locations.
- Experience managing 50+ clinical professionals, including hiring, training, performance management, and workforce planning.
- Knowledge of CMS regulatory requirements, HIPAA, and HITRUST compliance frameworks.
- Ability to lead cross-border teams across US and India time zones.
Responsibilities
- Set up and operationalize the clinical RN review function at the Hyderabad GIC, including workflows, staffing models, and technology enablement.
- Design a scalable operating model for prior authorization reviews across delegated specialties.
- Develop and maintain SOPs, work instructions, clinical review protocols, and decision-support frameworks.
- Recruit, train, mentor, and manage US NCLEX-certified RN reviewers, supervisors, and team leads.
- Oversee medical necessity reviews, clinical documentation assessment, guideline application, and referrals to US Medical Directors.
- Manage case volumes, workload distribution, staffing adequacy, and turnaround times across specialties and payer clients.
- Establish quality assurance processes, audits, scorecards, and continuous quality improvement activities.
- Ensure clinical operations comply with HIPAA, HITRUST, CMS, NCQA, and applicable state requirements.
- Coordinate hand-offs and operational collaboration between India and US teams, and report performance and workforce metrics to US leadership.
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