Program: Healthcare

Work Location: MOA, Pasay City

Work Setup: 100% Onsite

Shift Schedule: US Day Shift (Night Shift – Philippine Time)

Target Start Date: ASAP

THE ROLE

We are seeking a seasoned Senior Director / Vice President of Operations to lead large-scale Healthcare BPO operations, with a strong focus on Utilization Management (UM), Care Management, and Disease Management.

The successful candidate will provide end-to-end operational leadership for a 500–700 FTE organization, ensuring operational excellence, client satisfaction, regulatory compliance, financial performance, and effective people management.

This critical leadership position requires deep, hands-on healthcare domain expertise combined with proven experience managing large-scale operations and senior leadership teams.

USRN candidates with recent, hands-on Utilization Management experience are highly preferred. Candidates who combine clinical healthcare knowledge with strong BPO operational leadership will be given priority.

 KEY RESPONSIBILITIES

A. Strategic & Operational Leadership

• Provide overall leadership and direction for healthcare operations, ensuring consistent achievement of contractual KPIs, SLAs, quality, productivity, and compliance standards.

• Translate business and client objectives into operational strategies, execution plans, and measurable outcomes.

• Lead large, multi-layered leadership teams, including Directors, Senior Managers, and Operations Managers.

• Ensure stable, efficient, and scalable operations across healthcare programs.

B. Healthcare Delivery – Core Focus

• Oversee healthcare operations with direct experience in Utilization Management, Care Management, and Disease Management.

• Ensure operational excellence across the following healthcare processes:

  - Prior Authorization workflows

  - Prospective, Concurrent, and Retrospective Reviews

  - Appeals and Grievance Operations, where applicable

  - Clinical Review and Medical Necessity processes

• Ensure standardized workflows, productivity benchmarks, quality controls, and turnaround time discipline.

• Drive operational efficiency while maintaining compliance with U.S. healthcare requirements.

C. Client & Stakeholder Management

• Act as the executive sponsor for healthcare clients, building strong relationships with senior client stakeholders.

• Lead client governance forums, including weekly and monthly business reviews and Quarterly Business Reviews (QBRs).

• Proactively identify operational risks and implement performance improvement plans.

• Partner with Solutions, Transitions, and Sales teams on new program launches, expansions, and business initiatives.

D. Financial & Commercial Accountability

• Own operational cost management, budgeting, and margin improvement initiatives.

• Drive staffing efficiency, attrition management, productivity optimization, and process standardization.

• Maintain a strong P&L mindset across leadership teams.

• Ensure cost-to-serve discipline without compromising service quality and compliance.

E. Compliance, Risk & Governance

• Ensure strict adherence to healthcare regulatory, privacy, and data protection requirements, including PHI and HIPAA-aligned controls.

• Maintain audit readiness and strong internal controls for healthcare and UM operations.

• Partner with Quality and Compliance teams to address audit findings, mitigate risks, and implement corrective actions.

F. People Leadership & Talent Development

• Lead and inspire a 500–700 FTE organization.

• Develop and mentor senior leadership teams, including Directors, Senior Managers, and Operations Managers.

• Establish succession plans and strengthen leadership capabilities.

• Drive employee engagement, retention, accountability, and overall organizational performance.

G. Continuous Improvement & Transformation

• Identify and implement process improvements to drive efficiency, quality, and scalability.

• Leverage operational data, analytics, and performance insights for fact-based decision-making.

• Support automation, digitization, and transformation initiatives aligned with healthcare operations.

QUALIFICATIONS & REQUIREMENTS

Mandatory Qualifications:

• 10+ years of Healthcare Operations experience in a BPO, shared services, or captive environment.

• 5+ years of experience in senior leadership roles (Director, Senior Director, or equivalent and above).

• Proven experience managing 500+ FTEs in complex, multi-layered operations.

• Recent, hands-on experience in at least one or more of the following:

  - Utilization Management (UM)preferred

  - Care Management

  - Disease Management

• Strong understanding of U.S. healthcare processes, clinical workflows, and medical terminology.

• Knowledge of MCG/Milliman, InterQual, CMS guidelines, and HIPAA.

• Proven experience in executive client management, performance governance, and operational optimization.

• Strong background in performance management, leadership development, and operational analytics.

• Experience in forecasting, budgeting, and managing revenue and margin performance.

• Excellent communication, stakeholder management, and strategic decision-making skills.

• Bachelor's degree required in Nursing, Healthcare Administration, Business Administration, or a related field.

• Master's degree or MBA is preferred but not mandatory.

Highly Preferred: USRN + Utilization Management Experience

• Candidates with an active U.S. Registered Nurse (USRN) license are highly preferred.

• Recent, hands-on Utilization Management experience is strongly preferred.

• Candidates with both clinical healthcare experience and large-scale healthcare BPO operational leadership will be prioritized.

• Experience in Prior Authorization, Clinical Review, Medical Necessity, and related UM workflows is a strong advantage.

Important: General BPO leadership experience without direct healthcare domain exposure will not be sufficient for this position.

4. ADDED ADVANTAGE (NICE TO HAVE)

• Exposure to Medical Coding operations, including ICD-10, CPT, and HCC.

• Lean Six Sigma, Process Excellence, or other continuous improvement certifications.

• Experience managing multiple healthcare programs or accounts.

• Additional clinical or healthcare-related certifications.

***Note: Medical Coding experience is an added advantage, not a mandatory requirement.***