Sr. Director, Cinical Operations

Overview

Lead the establishment and management of the clinical RN review function at Cohere Health's Global Innovation Center in Hyderabad, India, delivering prior authorization clinical reviews for US payer clients.

What you'll do

• Lead the end-to-end setup and operationalization of the clinical RN review function at the Hyderabad GIC, including infrastructure, workflows, staffing models, and technology enablement via Cohere Unify™.
• Design and implement a scalable operating model for clinical prior authorization reviews across multiple delegated specialties (e.g., musculoskeletal, cardiology, radiology, diagnostic imaging).
• Develop and maintain SOPs, work instructions, clinical review protocols, and decision-support frameworks aligned with US clinical standards.
• Establish a shift operations model with overlap with US business hours for real-time case collaboration with US clinical leads and Medical Directors.
• Partner with US Clinical Operations leadership to define scope boundaries, with the India team handling clinical documentation review, medical necessity assessment support, and case preparation, while US-based clinical leads retain final determination authority for regulated states.
• Recruit, hire, and onboard a team of US NCLEX-certified RNs in India; build and sustain a talent pipeline for NCLEX-RN professionals in the Hyderabad market.
• Implement and oversee a 6-week blended training program for new RNs covering US healthcare system foundations, Cohere Unify™ and UM workflow training, MCG and CMS guidelines, and supervised clinical review with competency assessments.
• Design ongoing continuing education, clinical upskilling, and recertification programs to maintain clinical currency and US licensure compliance.
• Mentor and develop RN Supervisors, Team Leads, and RN Reviewers; conduct performance evaluations, competency assessments, and calibration sessions.
• Oversee daily clinical review operations, including medical necessity reviews, clinical documentation assessment, consistent guideline application, and timely referral of cases to US Medical Directors for peer-to-peer review.
• Manage case volumes, workload distribution, staffing adequacy, and turnaround times to meet CMS, NCQA, and client-specific standards.
• Establish and maintain a clinical quality assurance framework, including inter-rater reliability assessments, audit protocols, and quality scorecards.
• Ensure all clinical operations comply with HIPAA, HITRUST, CMS, NCQA, and applicable state regulatory requirements.
• Implement and track KPIs with specific targets.
• Serve as the primary India-based clinical operations leader, collaborating with the VP Global Ops Transformation, US Medical Directors, and VP Clinical Support Operations.
• Provide regular operational performance reports, clinical quality dashboards, and workforce analytics to US leadership, and serve as the escalation point for India GIC clinical operations issues.
• Manage ISMS responsibilities within the scope of the role, including ISMS documentation, risk assessments, risk treatment plans, BCP testing with the CISO, and implementation of security policies.

What you'll need

• 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, with at least 5 years in a senior leadership role.
• Knowledge and experience in utilization review / utilization management, including prospective (prior authorization), concurrent, and retrospective review.
• Proven experience setting up and managing clinical operations in a GCC/GIC/BPO/offshore environment, preferably 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 clinical criteria sets including MCG Care Guidelines, InterQual, and/or equivalent 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 (acute care, post-acute care, ambulatory, outpatient).
• Experience with CMS regulatory requirements, HIPAA, and HITRUST compliance frameworks.
• Proven track record of building clinical teams from the ground up in offshore settings.
• Experience managing 50+ clinical professionals, including hiring, training, performance management, and workforce planning.
• Demonstrated ability to lead cross-border, cross-functional teams across US and India time zones.
• Strong executive presence with the ability to influence senior stakeholders (C-suite, Medical Directors, Health Plan clients).
• Track record of driving continuous quality improvement and operational excellence in clinical settings.
• Good knowledge of information security.

Nice to have

• Certifications: CPHQ, CCM, CDIP, or equivalent.
• Experience with AI-driven clinical intelligence platforms and healthcare technology solutions.
• Prior experience at US health plans (payer-side) or managed care organizations in clinical operations leadership.
• NCLEX-RN training or clinical education background.
• Familiarity with delegated specialty models (MSK, cardiology, radiology, etc.).

Details

• Location: Remote in India, preferably in southern states; candidates in Hyderabad, Telangana must reliably commute or plan to relocate before starting.
• Work schedule: shift schedules for real-time collaboration with US clinical teams, with flexibility for extended hours during client launches, audits, or client requirements.
• Travel: occasional travel to the United States (estimated 2 per year) for leadership summits and training programs.
• Technology: proficiency with Google Workspace, Zoom, and Mac-based environments preferred; working knowledge of Cohere Unify™ preferred (training provided).