Sr. Director, Cinical Operations
Cohere Health
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Job summary
Cohere Health is seeking a Sr. Director to establish and lead the clinical RN review function at the Hyderabad GIC, delivering Medicare/Medicaid and commercial prior authorization reviews for US payer clients.
You will design scalable processes, recruit NCLEX-RN staff, and align with US clinical leaders to retain final determination authority while enabling offshore execution. Remote in India with overlap with US hours; growth-focused leadership role driving quality improvement, staff
Qualifications
- Bachelor’s degree in Nursing; US NCLEX-RN licensure required
- 12–15 years in clinical operations with 5+ years in senior leadership
- Proven experience building offshore clinical operations in GCC/GIC or similar
- Deep knowledge of US payer policies, UM/prior authorization, CMS/HIPAA/HITRUST
- Experience with MCG Care Guidelines and InterQual criteria
- Strong cross-border leadership and stakeholder management
Responsibilities
- Lead end-to-end setup and operationalization of the Hyderabad GIC clinical RN review function
- Design scalable operating model for prior authorization reviews across specialties
- Develop and maintain SOPs, work instructions, and decision-support frameworks
- Establish shift model to overlap with US business hours
- Partner with US leadership to define scope boundaries and final determinations remain with US team
- Recruit and onboard US NCLEX-certified RNs in India
- Implement 6-week blended training program and ongoing education
- Oversee daily clinical review operations ensuring accuracy and timeliness
- Maintain regulatory compliance with HIPAA, CMS, NCQA, and state requirements
- Monitor KPIs and drive continuous quality improvements
- Cross-functional collaboration with US teams to ensure consistency of criteria
- Report on performance metrics and escalation management
- Ensure completion and accuracy of Cohere Unify™ documentation
Skills
Education
Tools
Job description
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 clinicaloperations with India-based talent delivery, foster a culture of clinical excellence, and drivecontinuous quality improvement in a fast-paced, technology-driven environment.
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
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
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
- 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
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
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.
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
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
- 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.
- 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 (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 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
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.)
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
- Agility & Resilience: Thrives in a fast-paced startup environment characterized by ambiguity, rapid change, and exponential growth
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)
- Hyderabad, Telangana: Reliably commute or planning to relocate before starting work (Preferred)
- Connect with Talent Acquisition
- Meet with the Hiring Manager
- Behavioral Interview(s)
- Case Study
- Interview with Senior Leadership
*Subject to change
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.
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.
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