Senior Manager, Insurance and Claims Advocacy

PinnacleCare•Wellesley, MA

5d•$76,200 - $114,300•Hybrid

About The Position

The Senior Manager, Insurance and Claims Advocacy is a pivotal leader within the Clinical Solutions team at PinnacleCare, Sun Life U.S. Health and Risk Solutions. In this role, you will lead a comprehensive advocacy program that helps members navigate and maximize their health insurance while resolving complex medical billing and claim issues. You will set the vision, drive operational excellence, build scalable processes, and deliver measurable financial and experience outcomes—serving as the final escalation point for sensitive cases and establishing best practices across the organization.

Requirements

Ability to work with a diverse range of people
7+ years of experience in medical billing/claims advocacy, complex claims resolution, appeals, coordination of benefits, and insurance plan analysis (including pre-authorizations and enrollment support).
Bachelor’s degree in healthcare administration, business, or related field required; advanced degree and/or relevant certification preferred.
3+ years of progressive people leadership experience, with demonstrated success managing teams and service operations.
Deep knowledge of payer claims adjudication, CPT/ICD coding, and provider billing practices; strong negotiation and escalation management skills.
Proven ability to drive process improvement using data/analytics, technology platforms (e.g., Salesforce, MS Office), and responsible AI-enabled tools.
Excellent communication skills and ability to influence cross-functional stakeholders in a fast-paced environment.

Nice To Haves

advanced degree and/or relevant certification preferred

Responsibilities

Lead and develop a high-performing Insurance and Claims Advocacy team, including hiring, coaching, performance management, and workforce planning.
Own program strategy, service delivery standards, and key performance indicators across insurance navigation and claims resolution.
Oversee resolution of complex medical billing and insurance issues (denials and appeals, billing errors/coding discrepancies, out-of-network disputes), serving as the primary escalation point for sensitive cases.
Guide proactive insurance navigation, including benefits education, coverage guidance, and pre-service support to remove barriers and improve member outcomes.
Build and optimize scalable workflows, leveraging data, technology platforms, and responsible AI-enabled tools to improve quality, efficiency, and turnaround time.
Ensure accurate, audit-ready documentation and adherence to SOPs, regulations, and quality standards.
Partner cross-functionally (Sales, Client Service, Member Services, Analytics, and clinical teams) to implement improvements, support growth, and elevate the member experience.