Clinical Operations Consultant

Job Description

The ideal candidate understands how payers operate across the healthcare continuum, how global delivery models function, and how clinical teams partner with technology and analytics to modernize workflows.

Qualifications

• Active U.S. Registered Nurse (RN) license
• 13+ years of experience, including 8–10 years in payer/provider operations (utilization management, care management, claims)
• Experience in clinical workflow design, operations, or audits in healthcare environments
• Knowledge of payment integrity, risk adjustment, or CDI (preferred)
• Strong understanding of healthcare regulations (CMS, NCQA, URAC, HIPAA)
• Exposure to digital/AI tools and workflow automation
• Strong leadership, client-facing, and communication skills
• Proven ability to operate in fast-paced, dynamic environments

Key Responsibilities

• Operational Leadership: Lead global clinical operations ensuring delivery excellence in utilization management, care coordination, claims, and payment integrity.
• Solution & Process Design: Design scalable operating models for care management, triage, and cost-of-care programs
• Client Engagement: Serve as a trusted advisor to clients, guiding strategy, quality, and performance discussions.
• Innovation & Enablement: Collaborate with technology and analytics teams to embed AI and digital solutions that enhance decision-making, compliance, and patient outcomes.
• Regulatory & Compliance: Ensure adherence to CMS, NCQA, URAC, and HIPAA standards, maintaining audit readiness and mitigating compliance risks.

Our client is an Equal Opportunity Employer, committed to a workplace free from discrimination and harassment. Employment decisions are based on business needs, job requirements, and individual qualifications without regard to race, color, religion, gender, age, disability, sexual orientation, gender identity, marital status, military service, genetic information, or any other status protected by law.