Senior Director, Clinical Operations

🔥 3 hours ago

🇮🇳 India – Remote

⏰ Full Time

🟠 Senior

🏥 Clinical Operations

👻 Ghost score 12%

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Cohere Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Cohere Health is a company focused on transforming the prior authorization process in healthcare using advanced technologies. The company offers the Cohere Unify™ Platform, which includes artificial intelligence and machine learning capabilities to improve utilization management (UM) and facilitate quicker access to patient care. By digitizing the prior authorization process and integrating with electronic medical records, Cohere Health aims to enhance the quality of healthcare outcomes and reduce the administrative burden on providers. Their solutions help decrease denial rates and adverse outcomes through evidence-based intelligence and real-time clinical suggestions. Cohere Health's offerings are available as Platform as a Service (PaaS) or as fully outsourced solutions.

📋 Description

• Establish, scale, and manage the clinical RN review function at Cohere Health’s Hyderabad Global Innovation Center • Lead setup and operationalization of infrastructure, workflows, staffing models, and technology enablement via Cohere Unify™ • Design and implement scalable operating models 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 • Establish shift operations overlapping with US business hours for real-time collaboration • Partner with US Clinical Operations leadership to define India team scope and US final-determination responsibilities • Recruit, hire, onboard, mentor, and develop US NCLEX-certified RN teams in India • Build the Hyderabad NCLEX-RN talent pipeline and oversee a six-week blended training program • Design continuing education, clinical upskilling, and recertification programs • Oversee daily medical necessity reviews, clinical documentation assessment, guideline application, and Medical Director referrals • Ensure accurate and timely documentation in Cohere Unify™ • Manage case volumes, workload distribution, staffing adequacy, and turnaround times • Establish clinical quality assurance frameworks, including IRR assessments, audits, and quality scorecards • Ensure compliance with HIPAA, HITRUST, CMS, NCQA, and applicable state regulations • Drive accreditation compliance, quality improvement activities, and KPI tracking • Collaborate with US Medical Directors, Clinical Operations, Provider Relations, Operations, Product, Implementation, Compliance, Quality, and Health Plan Account Management teams • Facilitate India-US handoffs and represent India GIC clinical operations in governance forums, operational reviews, client readiness reviews, audits, and escalations • Provide operational performance reports, clinical quality dashboards, and workforce analytics to US leadership • Contribute to business cases for expanding scope, adding specialties, and scaling capacity • 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 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, 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 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 • 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 • Ability to lead cross-border, cross-functional teams across US and India time zones • Strong executive presence and ability to influence and collaborate with senior stakeholders • Track record of driving continuous quality improvement and operational excellence in clinical settings • Proficiency with Google Workspace, Zoom, and Mac-based environments preferred • Willingness to work shift schedules with flexibility for extended hours during client launches, audits, or client requirements • Preferred: CPHQ, CCM, CDIP, or equivalent certification; AI-driven clinical intelligence platforms; US health plan or managed care experience; NCLEX-RN training or clinical education; familiarity with delegated specialty models

🏖️ Benefits

• Occasional travel to the United States (estimated 2 per year) for leadership summits and training programs • Training provided for the Cohere Unify™ platform • Equal employment opportunities in a respectful workplace

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