Lead a clinical operations team that reviews prior authorization cases for medical necessity, documentation completeness, and guideline alignment across multiple specialties for U.S. payer clients. The work centers on building and scaling RN-led utilization review operations, including prospective, concurrent, and retrospective reviews, with clinical determinations supported by U.S.-based medical directors. This role also includes team development, workflow design, quality monitoring, and cross-border coordination in a technology-enabled environment.
Key Responsibilities
- Build and operationalize the RN clinical review function, including workflows, staffing models, infrastructure, and technology use.
- Design scalable prior authorization review processes across delegated specialties such as musculoskeletal, cardiology, radiology, and diagnostic imaging.
- Develop and maintain SOPs, work instructions, clinical review protocols, and decision-support frameworks.
- Recruit, hire, onboard, and develop NCLEX-certified RNs and RN leaders.
- Oversee daily review operations for prior authorization, retrospective review, out-of-network review, and treatment setting review.
- Ensure accurate application of clinical guidelines, internal criteria, and coverage determinations.
- Coordinate timely escalation of nonconforming cases to U.S.-based Medical Directors for final review.
- Monitor quality, turnaround times, KPIs, and compliance with regulatory and accreditation standards.
- Collaborate with U.S. clinical, operational, quality, compliance, and account teams on case handling and service alignment.
Required
- Bachelor’s degree in Nursing (BSN).
- Active U.S. Registered Nurse license (NCLEX-RN).
- 12–15 years of progressive experience in clinical operations, utilization management, or healthcare operations.
- At least 5 years of senior leadership experience.
- Experience with prospective, concurrent, and retrospective utilization review.
- Experience managing clinical operations in a GCC/GIC/BPO/offshore environment serving U.S. healthcare clients.
- Experience with MCG Care Guidelines, InterQual, or similar evidence-based criteria.
- Experience with CMS requirements and HIPAA/HITRUST compliance frameworks.
Preferred
- CPHQ, CCM, CDIP, or equivalent quality or case management certification.
- Experience with AI-driven clinical intelligence platforms or healthcare technology solutions.
- Prior experience in U.S. health plans or managed care clinical operations.
- Experience managing NCLEX-RN teams in India or other offshore locations.
- Familiarity with delegated specialty models such as MSK, cardiology, and radiology.
Benefits & Perks
- Opportunity to build a new clinical operations function from the ground up.
- Technology-enabled workflow using Cohere Unify™.
- Cross-border collaboration with U.S. clinical leaders and medical directors.
- Structured training and supervised onboarding for new RN staff.
- Ongoing continuing education, clinical upskilling, and recertification support.
- Quality improvement and professional development opportunities.