Sr. Director, Cinical Operations

About this role

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…