Sr. Director, Cinical Operations

Job description

**Opportunity Overview:** The Sr. Director, GIC India Clinical Operations is a foundational leadership role responsible for establishing, scaling, and managing the clinical RN review function within Cohere Health's Global Innovation Center (GIC) in Hyderabad, India. This leader will build a high-performing team of US NCLEX-certified Registered Nurses (NCLEX-RNs) who perform prospective, concurrent, and retrospective clinical reviews for prior authorization cases on behalf of Cohere Health's US payer clients. The Sr. Director will be accountable for the end-to-end clinical operations delivery from the India GIC, ensuring that RN reviewers assess medical records and clinical documentation for appropriateness and medical necessity in strict alignment with clinical guidelines (including MCG Care Guidelines), Cohere Health internal criteria, National and Local Coverage Determinations (NCD/LCD), and regulatory standards (CMS, NCQA, HIPAA, HITRUST). This role operates within Cohere Health's push-pull delivery framework, where the US retains program ownership, process design, client relationships, and final clinical determination authority, while the India GIC executes clinical review operations per established SOPs and work instructions. This is a highly strategic role requiring a leader who can bridge US healthcare clinical operations with India-based talent delivery, foster a culture of clinical excellence, and drive continuous quality improvement in a fast-paced, technology-driven environment. **What you’ll do:** Clinical Operations Setup & Strategy - 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) served by Cohere Health's payer clients - Develop and maintain Standard Operating Procedures (SOPs), work instructions, clinical review protocols, and decision-support frameworks aligned with US clinical standards - Establish a shift operations model to ensure overlap with US business hours based on client requirements for real-time case collaboration with US clinical leads and Medical Directors - Partner with US Clinical Operations leadership to define scope boundaries — ensuring the India team handles clinical documentation review, medical necessity assessment support, and case preparation, while US-based clinical leads retain final determination authority for regulated states Talent Acquisition, Development & Management - Recruit, hire, and onboard a team of US NCLEX-certified RNs in India with strong clinical backgrounds, utilization management experience, and familiarity with US healthcare delivery systems - Build and sustain a robust talent pipeline for NCLEX-RN professionals in the Hyderabad market, partnering with HR and external agencies as needed - Implement and oversee a comprehensive 6-week blended training program for newly hired RNs: - Weeks 1–2: US healthcare system foundations (payer landscape, regulatory environment, medical terminology, clinical documentation standards) - Weeks 3–4: Cohere Unify™ platform training, UM workflow training, MCG, CMS Care Guidelines, and Cohere Health internal clinical criteria - Weeks 5–6: Supervised clinical review with US clinical mentor pairing, case simulations, and 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 individual RN Reviewers, fostering a culture of accountability, clinical curiosity, and patient-centric decision-making - Conduct regular performance evaluations, competency assessments, and calibration sessions aligned with US clinical quality benchmarks Clinical Review Operations Management - Oversee the daily execution of clinical review operations, ensuring RN Reviewers perform the following functions with accuracy and timeliness: - Medical necessity reviews: prior authorization, retrospective review, out-of-network review, and treatment setting reviews - Clinical documentation assessment: review of medical records, clinical notes, diagnostic results, and provider submissions for appropriateness and completeness - Guideline application: consistent application of MCG Care Guidelines, Cohere Health internal criteria, and National/Local Coverage Determinations across all delegated specialties - Medical Director consultation: timely and accurate referral of cases that do not meet applicable criteria or medical policies to US-based Medical Directors for peer-to-peer review and determination - Ensure complete, accurate, and timely clinical documentation within the Cohere Unify™ platform - Manage case volumes, workload distribution, and staffing adequacy across specialties and payer client portfolios - Monitor and manage turnaround times (TAT) for UM decision determinations to ensure compliance with CMS, NCQA, and client-specific timeliness standards Quality, Compliance & Accreditation - Establish and maintain a clinical quality assurance framework, including inter-rater reliability (IRR) assessments, audit protocols, and quality scorecards - Ensure all clinical operations comply with HIPAA, HITRUST, CMS, NCQA, and applicable state regulatory requirements - Drive compliance with accreditation standards, ensuring UM decision determinations and timeliness standards meet or exceed regulatory thresholds - Support the Quality Program by identifying, designing, and participating in quality improvement activities related to internal programs, processes, studies, and projects - Monitor and enforce adherence to Cohere Health's clinical criteria, authorization requirements, and payer-specific policies across Commercial, Medicare, and Medicaid lines of business - Implement and track key performance indicators (KPIs) with specific targets. Cross-Functional & Cross-Border Collaboration - Serve as the primary India-based clinical operations leader, collaborating closely with the VP Global Ops Transformation, US Medical Directors, and VP Clinical Support Operations - Partner with US-based teams including Provider Relations, Operations, Product, Implementation, Compliance, Quality, and Health Plan Account Management to ensure consistent application of clinical criteria and alignment with client expectations - Facilitate real-time and asynchronous hand-offs between India and US clinical teams via Cohere Unify™, shared metrics dashboards, and structured communication protocols - Participate in governance forums, operational reviews, and escalation management as the India GIC clinical operations representative - Collaborate with US clinical leads to promote the CarePath concept and ensure optimal patient outcomes across the care continuum Stakeholder Management & Reporting - Provide regular operational performance reports, clinical quality dashboards, and workforce analytics to US leadership - Serve as the escalation point for clinical operations issues originating from the India GIC - Represent the India GIC clinical operations function in client readiness reviews, regulatory audits, and internal governance meetings - Contribute to business case development for expanding clinical review scope, adding new specialties, or scaling team capacity **ISMS roles and responsibilities(** Manager Roles) - Good knowledge of Information security - Oversee specific business processes within the ISMS. - Responsible to manage the ISMS documentation, conduct risk assessments, and implement risk treatment plans. - Risk Owners are responsible for identifying, assessing, and managing risks within their areas of responsibility. - They are also responsible for implementing risk treatment plans. - Conduct the BCP and other test related to information security continuity along with CISO - Responsible for monitoring and reporting on the performance of the ISMS. - Responsible for implementation of security policies and procedures and report any issues to the CISO. **Required Qualifications:** Education - Bachelor's degree in Nursing (BSN) — Required - Active, US Registered Nurse license (NCLEX-RN) — Required Clinical & Professional 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 - 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 Leadership & Management - 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 and collaborate with senior stakeholders (C-suite, Medical Directors, Health Plan clients) - Track record of driving continuous quality improvement and operational excellence in clinical settings Preferred Qualifications - Certifications: CPHQ (Certified Professional in Healthcare Quality), CCM (Certified Case Manager), CDIP (Certified Documentation Improvement Practitioner), 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 (ability to contribute to staff credentialing and development programs) - Familiarity with delegated specialty models (MSK, cardiology,, radiology,, etc.) Core Competencies - Clinical Acumen: Deep understanding of medical necessity determination, clinical documentation integrity, and evidence-based care guidelines applied in a UM context - Operational Excellence: Ability to design, implement, and optimize high-volume clinical review operations with measurable quality and productivity outcomes - Cross-Cultural Leadership: Proven ability to lead India-based teams delivering US healthcare services, bridging cultural, regulatory, and operational differences - Strategic Thinking: Capacity to translate organizational strategy into operational execution, with a focus on scalability, compliance, and continuous improvement - Regulatory Expertise: Comprehensive knowledge of US healthcare regulations (CMS, HIPAA, HITRUST) and their application in offshore delivery models - Technology Enablement: Comfort with AI-driven platforms, clinical decision-support tools, and real-time analytics dashboards for managing distributed clinical teams - Stakeholder Communication: Excellent written and verbal communication skills; ability to present operational metrics, risk assessments, and strategic recommendations to US executive leadership - Agility & Resilience: Thrives in a fast-paced startup environment characterized by ambiguity, rapid change, and exponential growth Working Conditions & Additional Information - Location: Remote in India preferably in southern states. - Work Schedule: Shift schedules for real-time collaboration with US clinical teams; 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 (G Suite), Zoom, and Mac-based environments preferred; working knowledge of Cohere Unify™ platform (training will be provided) **Ability to commute/relocate:** - Hyderabad, Telangana: Reliably commute or planning to relocate before starting work (Preferred) **Interview Process\*:** 1. Connect with Talent Acquisition 2. Meet with the Hiring Manager 3. Behavioral Interview(s) 4. Case Study 5. Interview with Senior Leadership \*Subject to change **About Cohere Health:** Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum–including policy, prior authorization, payment accuracy, and more–the company improves collaboration and reduces burden, resulting in up to 8x ROI and 94% provider satisfaction. With the acquisition of ZignaAI, we expanded our AI-native platform with a comprehensive Payment Integrity Suite that spans data mining, clinical and coding validation, authorization and claims reconciliation, and end-to-end payment integrity services across pre- and post-pay workflows. By connecting clinical and payment insights, our transparent, AI-powered solutions help health plans proactively improve payment accuracy, reduce waste and vendor dependency, strengthen provider relationships, and build smarter, more efficient payment integrity programs. Cohere Health’s innovations continue to receive industry-wide recognition. We’ve been recognized on TIME’s World Top HealthTech Companies 2025 list, the 2025 Inc. 5000 list, in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. **We can’t wait to learn more about you and meet you at Cohere Health!** **Equal Opportunity Statement:** Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.