Senior Billing & Insurance Advisor

1. What’s the major objective(s) of the role?  

Major Objectives: Expert medical billing advocacy, insurance claims resolution, and Medicare/private insurance analysis, plan comparison, and enrollment assistance.  

2. What are the MUST-HAVE technologies?

Insurance Advocacy

1.     Microsoft Office (Excel, Word, Outlook) Experience To Complete The Following:

·         Excel: track claims, payments, balances, timelines, and appeal status accurately

·         Word: draft clear appeal letters, billing correction requests, and case summaries

·         Outlook: manage high-volume follow-up communications and reminders

2.     PDF/Document Reader/Editor Such as Adobe to complete the following:

·         Review and reconcile bills, EOBs, and carrier correspondence.

·         Organize documentation to support appeals and escalations.

·         Edit and Complete Necessary Claim Forms and Provider Forms.

·         Combine and annotate client files accordingly.

3.     Insurance Carrier Portals & Call Systems to complete the following:

·         Check claim status, payment details, and authorization requirements

·         Navigate long or complex calls efficiently and document outcomes clearly

·         Escalate appropriately within carrier structures when needed

·         Coverage Confirmations, Assisting with Premium Payments

Insurance Plan Analysis and Enrollment Assistance

1.     Microsoft Office (Excel, Word, Outlook)

·         Excel: build clean side-by-side comparisons (premium, deductible, MOOP, copays, coinsurance, out-of-network rules)

·         Word: create polished, client-ready reports and written recommendations

·         Outlook: manage member communication and follow-ups professionally

2.     PDF / Document Management tools (Adobe or similar)

·         Extract and organize key details from plan documents, bills/EOBs, and coverage letters

·         Combine, annotate, and support client files with proper documentation

3.     Carrier / plan portals and search tools

·         Use carrier portals and network search tools efficiently (provider/facility lookups, formulary checks, benefit summaries, prior auth rules)

·         Navigate Medicare tools as needed (Medicare.gov resources, SEP/ICEP rules references, plan tools)

4.     CRM / Case documentation tools (Salesforce)

·         Document coverage guidance, recommendations, and case status clearly

·         Track client cases from intake through resolution with accurate notes and follow-ups

3.What are the MUST-HAVE Critical Skills?

1.     Medical Billing & Claims Analysis

·         Understand how claims flow from provider → payer → patient

·         Spot common billing errors, denial patterns, and payment issues

·         Know when a claim needs correction vs. appeal vs. escalation

2.     Persistence & Follow-Through

·         Diligence on long-running cases without letting them stall

·         Proactively follow up with carriers and providers until resolution

·         Keep pressure on timelines while remaining professional

3.     Problem-Solving & Critical Thinking

·         Assess incomplete or conflicting information and determine next steps

·         Adjust strategy when claims or appeals are delayed or mishandled

·         Identify the most effective path to resolution for each situation

4.     Clear, Professional Communication

·         Explain complex billing and insurance issues in plain language         

·         Communicate confidently with providers, insurers, and clients

·         De-escalate tense billing situations while advocating firmly

5.     Organization & Case Ownership

·         Manage multiple active claims simultaneously

·         Prioritize cases based on urgency and financial impact

·         Take ownership from intake through final resolution

6.     Policy interpretation + insurance expertise

·         Understand and explain policy terms, limitations, exclusions, and authorization/referral rules

·         Accurately advise clients on what the plan will/won’t cover and what steps are required

7.     Analytical thinking + attention to detail

·         Catch details that impact member outcomes (network status, effective dates, prior auth triggers, coverage nuances)

·         Build comparisons that are accurate and defensible

8.     Client communication + education

·         Translate insurance language into clear and calm guidance

·         Set expectations and reduce anxiety while remaining factual and compliant

·         Deliver recommendations that are easy for clients to follow

9.     Ownership + organization

·         Manage multiple cases simultaneously without losing tasks

·         Follow through with a strong sense of accountability and timeliness

10.  Professional advocacy / stakeholder navigation

·         Confidently engage carriers, providers, and third parties when needed

·         Escalate effectively and maintain professionalism throughout

4. What are the NICE TO HAVE technologies?

1.     Medicare & Medicaid claims experience

2.     Experience with Commercial Insurances including but not limited to:  Anthem, Cigna, BCBS, UHC, Aetna (How to handle calls and submit claims to each.)

3.     Appeals experience (medical necessity, authorization, timely filing, coding)

4.     Basic coding familiarity (CPT/HCPCS/ICD)

5.     Medicare plan knowledge (supplements vs advantage, enrollment periods/SEPs, IRMAA awareness, etc.)

6.     Experience with plan design and underwriting concepts (ACA vs off-exchange, EPO/PPO/HMO rules, COBRA transitions)

7.     Basic medical billing awareness (EOB interpretation, common denial reasons)

8.     Salesforce

Position Summary: ClaimMedic is a health insurance navigation and billing negotiation arm of PinnacleCare, at Sun Life. The Senior Billing & Insurance Advisor to provide expert medical billing advocacy, insurance claims resolution, and private insurance report generation. This role ensures clients receive high-touch, end-to-end support across all ClaimMedic products. Additionally, the Senior Billing & Insurance Advisor acts as a subject matter expert and mentor within the team, supporting cross-training, best practices, and operational excellence.

Essential Functions and Responsibilities:

Client Advocacy & Case Management

·         Provide advocacy services for comprehensive and group members, including review, escalation, and negotiation of medical bills and insurance claims.

·         Manage complex cases requiring coordination with multiple providers, carriers, and third-party entities.

·         Maintain consistent client communication to ensure transparency, education, and resolution.

Private Insurance Reports & Consultations

·         Prepare detailed private insurance reports for individuals and families, outlining plan options, benefits, exclusions, and financial considerations.

·         Conduct consultations to explain findings, recommend coverage strategies, and support client decision-making

·         Monitor regulatory and market changes to ensure recommendations remain current and compliant.

Cross-Product Service Delivery & Team Leadership

·         Deliver advocacy services across all ClaimMedic products with consistency and quality, act as a resource for complex cases and escalations.

·         Serve as a subject matter expert for insurance navigation, billing audits, appeals, and coverage analysis, providing day-to-day guidance and coaching to Billing Advocate Associates.

·         Mentor new hires during onboarding, serving as the primary peer resource for training and knowledge transfer.

·         Conduct periodic case reviews to reinforce learning and ensure adherence to policies, providing constructive feedback to promote skill development and professional growth.

·         Serve as an escalation point for complex or sensitive cases, ensuring resolution is both effective and diplomatic.

·         Partner with the Senior Manager on workflow oversight, resource allocation, and case prioritization and serve as acting lead when the Senior Manager is unavailable.

·         Assist in drafting, reviewing, and refining SOPs.

·         Document all case activities in Salesforce in alignment with departmental SOPs.

·         Support data collection for proof points, reporting, and departmental performance metrics.

·         Collaborate on identifying process gaps and recommending improvements.

Position Requirements and Qualifications:

·         5+ years of experience in health insurance, medical billing, or insurance advocacy.

·         Strong knowledge of commercial insurance, Medicare, Medicaid, and expat/global plans.

·         Proven expertise in medical billing audits, appeals, and coordination of benefits.

·         Experience with enrollment and private insurance report preparation preferred.

·         Exceptional verbal, written, and interpersonal communication skills.

·         Excellent organizational and prioritization skills; able to manage multiple client matters simultaneously.

·         Computer proficiency in MS Office; Salesforce experience preferred.

·         Ability to handle sensitive situations with diplomacy and tenacity.

·         Team player with a strong work ethic and ‘can do’ attitude.

·         Experience mentoring or coaching peers is preferred.