Senior Client Services Representative

3 days ago


West Columbia, South Carolina, United States Pyramid Consulting Full time
Job Summary

We are seeking a highly skilled and experienced Senior Client Services Representative to join our team at Pyramid Consulting. As a key member of our client services team, you will be responsible for providing exceptional customer service to our clients, resolving complex inquiries, and ensuring timely and accurate processing of claims and appeals.

Key Responsibilities
  • Customer Service: Provide prompt, accurate, and courteous responses to all complex inquiries from Medicare Advantage members and providers.
  • Claims Processing: Review and adjudicate complex or specialty Medicare claims and/or non-medical appeals, determining whether to return, deny, or pay claims following organizational and governmental policies and procedures.
  • Research and Analysis: Perform research as needed to resolve inquiries, identify underlying causes, and determine ways to prevent and correct such causes.
  • Compliance and Quality: Ensure compliance with organizational and governmental policies and procedures, as well as contract standards and Federal and organizational objectives for timeliness, productivity, and quality.
  • Communication and Collaboration: Respond to complex Medicare Part C and Part D questions, ensure CMS coordination of benefit reconciliation is accurate, and answer escalated provider inquiries.
Requirements and Qualifications
  • Education: High school diploma or equivalency.
  • Experience: 3 years of customer service experience, including 1 year of claims or appeals processing experience.
  • Skills: Good verbal and written communication skills, strong customer service skills, basic business math abilities, ability to handle confidential or sensitive information with discretion.
  • Technology: Microsoft Office, familiarity with CMS enrollment, disenrollment policies, and ITS rule and regulations.


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