Sr. Director, Cinical Operations
Core
Sr. Director leading the setup and management of a clinical RN review function in India for US payer clients, performing prospective, concurrent, and retrospective reviews for prior authorization cases.
Role type
Sr. Director, Clinical Operations (India GIC)
Builds
Scalable clinical review operations for prior authorization across multiple delegated specialties (musculoskeletal, cardiology, radiology, diagnostic imaging) for US payer clients.
Domain
US Healthcare Payer Operations / Utilization Management / Clinical Review
Required skills
Clinical operations leadership, team building and talent acquisition, US healthcare system knowledge, utilization management experience, regulatory compliance (HIPAA, CMS, NCQA), quality assurance, cross-border collaboration, SOP development, performance management.
Preferred skills
Experience with MCG Care Guidelines, Cohere Unify platform, shift operations management, risk assessment (ISMS), BCP testing.
Technologies
Cohere Unify™, MCG Care Guidelines, CMS Care Guidelines, HIPAA, HITRUST, NCQA standards.
Responsibilities
Lead end-to-end setup and operationalization of clinical RN review function; Recruit and train US NCLEX-certified RNs; Oversee daily execution of medical necessity reviews and clinical documentation assessment; Ensure compliance with US clinical guidelines and regulatory standards; Manage case volumes, workload distribution, and turnaround times; Establish quality assurance frameworks and audit protocols; Collaborate with US Medical Directors and clinical leads for complex cases.
Seniority
Senior, strategic leadership with hands-on operational oversight