Senior Director, Clinical Operations

This is a fully remote position, open to applicants in India.

📋 Description

• Establish, scale, and oversee the clinical RN review function at Cohere Health’s Hyderabad Global Innovation Center.

• Lead the setup and operational implementation of infrastructure, workflows, staffing models, and technology enablement through Cohere Unify™.

• Design and execute scalable operating models for clinical prior authorization reviews across delegated specialties.

• Develop and uphold SOPs, work instructions, clinical review protocols, and decision-support frameworks that align with US clinical standards.

• Set up shift operations that overlap with US business hours to facilitate real-time collaboration.

• Collaborate with US Clinical Operations leadership to outline the scope of the India team and the responsibilities for US final determinations.

• Recruit, hire, onboard, mentor, and nurture US NCLEX-certified RN teams based in India.

• Build a robust talent pipeline of NCLEX-RN professionals in Hyderabad and oversee a six-week blended training program.

• Create continuing education, clinical upskilling, and recertification programs.

• Supervise daily medical necessity reviews, clinical documentation assessments, guideline applications, and Medical Director referrals.

• Ensure documentation accuracy and timeliness in Cohere Unify™.

• Manage case volumes, workload distribution, staffing adequacy, and turnaround times.

• Establish frameworks for clinical quality assurance, including IRR assessments, audits, and quality scorecards.

• Ensure adherence to HIPAA, HITRUST, CMS, NCQA, and relevant state regulations.

• Drive compliance with accreditation standards, quality improvement initiatives, and KPI tracking.

• Collaborate with US Medical Directors, Clinical Operations, Provider Relations, Operations, Product, Implementation, Compliance, Quality, and Health Plan Account Management teams.

• Facilitate handoffs between India and the US, representing India GIC clinical operations in governance forums, operational reviews, client readiness assessments, audits, and escalations.

• Provide operational performance reports, clinical quality dashboards, and workforce analytics to US leadership.

• Contribute to business cases for scope expansion, specialty additions, and capacity scaling.

• Oversee ISMS processes, documentation, risk assessments, risk treatment plans, business continuity testing, security policy implementation, and performance reporting.

⛳️ Requirements

• Bachelor’s degree in Nursing (BSN) — Required.

• Active US Registered Nurse license (NCLEX-RN) — Required.

• Minimum of 12–15 years of progressive experience in clinical operations, utilization management, and/or healthcare operations, with at least 5 years in a senior leadership position.

• Knowledge and experience in utilization review/utilization management, including prospective, concurrent, and retrospective review.

• Proven experience in establishing and managing clinical operations in a GCC/GIC/BPO/offshore environment, ideally serving US healthcare payer clients.

• Demonstrated expertise in US healthcare delivery systems, payer operations, and the prior authorization lifecycle across Commercial, Medicare, and Medicaid lines of business.

• Hands-on experience with MCG Care Guidelines, InterQual, and/or similar evidence-based criteria.

• Experience managing NCLEX-certified RN teams in India or other offshore locations.

• Knowledge of clinical algorithms, care pathways, and utilization management across the care continuum.

• Familiarity with CMS regulatory requirements, HIPAA, and HITRUST compliance frameworks.

• Proven track record in building clinical teams from the ground up in offshore environments.

• Experience overseeing 50+ clinical professionals, including hiring, training, performance management, and workforce planning.

• Capability to lead cross-border, cross-functional teams across US and India time zones.

• Strong executive presence with the ability to influence and collaborate with senior stakeholders.

• History of driving continuous quality improvement and operational excellence in clinical settings.

• Proficiency with Google Workspace, Zoom, and Mac-based environments is preferred.

• Willingness to work shift schedules with flexibility for extended hours during client launches, audits, or client demands.

• Preferred: CPHQ, CCM, CDIP, or equivalent certification; experience with AI-driven clinical intelligence platforms; background in US health plan or managed care; training or clinical education in NCLEX-RN; familiarity with delegated specialty models.

🏝️ Benefits

• Occasional travel to the United States (approximately 2 times per year) for leadership summits and training programs.

• Training provided for the Cohere Unify™ platform.

• Equal employment opportunities in a respectful workplace.