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Healthcare Provider Operations, Utilization Management

Diverse Lynx
  • US
    Austin, Texas, United States
  • US
    Austin, Texas, United States

Über

Clinical Operations Consultant The Clinical Operations Consultant is a seasoned Registered Nurse who combines deep payer-side clinical experience with operational and strategic insight. This role bridges clinical operations, business process design, and solution enablement, helping to shape and scale delivery models that drive measurable impact. 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. They will serve as a clinical voice and process architect, translating client requirements into scalable, efficient solutions and collaborating with global nursing and technology teams to deploy tools and accelerators that improve quality, speed, and cost. This position requires strong clinical judgment, people leadership experience, and the ability to move seamlessly between operational detail and strategic vision. Key Responsibilities
Operational Leadership – Serve as the clinical anchor for organization's global delivery framework. Provide direction and oversight to cross-shore teams across the U.S., Philippines, and India to ensure every program, utilization management, care coordination, claims, and payment integrity, is executed with clinical integrity, operational discipline, and measurable quality. Drive performance governance, mentor emerging leaders, and maintain alignment to client objectives and organization standards. Solution and Process Design – Translate payer and client needs into structured, scalable operating models. Design frameworks for care management, triage, and cost-of-care programs that blend clinical evidence, process efficiency, and technology enablement. Create methodologies that can be replicated and measured for impact across engagements. Client Engagement and Collaboration – Act as a trusted advisor and subject-matter expert during client interactions, steering discussions around strategy, quality, and performance outcomes. Partner with payer stakeholders to define goals, refine operating models, and ensure organization's solutions deliver clinical and financial value. Innovation and Enablement – Collaborate with technology, analytics, and AI teams to embed clinical intelligence into organization's AI and digital accelerators initiatives. Ensure that innovation enhances decision quality, compliance, and patient outcomes. Regulatory and Compliance Leadership – Safeguard adherence to CMS, NCQA, and URAC standards across all designed and delivered processes. Maintain documentation rigor, anticipate compliance risks, and guide remediation efforts in collaboration with governance and audit teams.
Qualifications
Active Registered Nurse (RN) license in the United States. 13 years of overall relevant experience; 8–10 years of experience in payer or provider operations, with strong grounding in utilization management, care management, and claims. Proven experience designing or managing clinical workflows, audits, or operations in a payer or BPS environment. Working knowledge of payment integrity, risk adjustment, and clinical documentation improvement (CDI) preferred. Demonstrated expertise in healthcare regulatory and compliance requirements (e.g., CMS, NCQA, URAC, HIPAA). Familiarity with technology enablement (automation, workflow tools, AI accelerators, or digital platforms) — able to partner effectively with tech and analytics teams. Strong leadership, client-facing, and communication skills. Demonstrated ability to create structure, prioritize, and deliver results in dynamic, fast-paced settings.
Diverse Lynx LLC is an Equal Employment Opportunity employer. All qualified applicants will receive due consideration for employment without any discrimination. All applicants will be evaluated solely on the basis of their ability, competence and their proven capability to perform the functions outlined in the corresponding role. We promote and support a diverse workforce across all levels in the company.
  • Austin, Texas, United States

Sprachkenntnisse

  • English
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