Call Center Representative-Health Plan-Work from home

Presbyterian Healthcare is seeking a Call Center Representative to provide exceptional customer service for Health Plan members. This work-from-home role requires candidates to be located in the metro Albuquerque, NM area.

In this role, you'll be the first point of contact for patients-whether it's over the phone, through chat, email, or in person-providing support and answers with empathy and professionalism. You'll help coordinate appointments, referrals, and messaging, while keeping patient information up to date. Every interaction is an opportunity to deliver excellent service and create a positive experience. You'll also ensure all documentation is accurate and aligned with policy standards.

This is a Full Time position- Exempt: No
• Job is based Rev Hugh Cooper Admin Center

Ideal Candidate:

• Strong communication and customer service skills
• Ability to navigate multiple systems and respond efficiently to inquiries
• Committed to delivering high-quality support for patients and the Health Plan

• High school diploma plus one to three years office/business experience; call center experience preferred and/or is currently demonstrating customer service skills, meeting current department metric and attendance guidelines within department.
• Claims processing experience in managed care with possible enrollment experience is preferred.
• Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, and physician office staff. Written communication skills as well as business writing and presentation skills are required.
• Requires strong organizational skills, ability to create, sort and analyze reports (Excel, Access, etc) and system processes.
• A thorough knowledge of reimbursement methodologies i.e. DRG, Relative Value Systems, Per Diem, Fee schedule, Capitation, etc and some knowledge of risk sharing programs helpful.
• Some knowledge of CRM and Facets, as well as any other databases that may be used PHS Enterprise wide.
• Demonstrated ability to function effectively as a team member. Requires ability to retain plan details and basic medical terminology.
• Must be able to work cooperatively with other employees and function under pressure. Demonstrated ability to sustain quality standards. Must be able to prove ability to type 30 wpm with 90% accuracy.

• Respond to member and provider inquiries regarding benefits, coverage, premiums, eligibility, and PCP changes.

• Handle inbound and outbound calls using skill-based routing to meet quality and performance standards.

• Build positive relationships and advocate for members with practitioners, employer groups, and brokers.

• Represent PHS/PHP at outreach events such as health fairs, job fairs, and focus groups.

• Support process improvements by documenting procedures and analyzing patterns in inquiries and claims.

• Research and resolve inquiries using tools like D.A.R.T., Provider Manual, and Pres Online.

• Collaborate effectively within teams and contribute to improvement initiatives.

• Accurately record all member interactions across various communication channels.

• Help coordinate meetings for training, contracting, and reporting as needed.

• Perform additional duties as assigned.

About Presbyterian Healthcare Services

Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits.

The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities-like challenges, webinars, and screenings-with opportunities to earn gift cards and other incentives.

As a mission-driven organization, Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers' markets and local partnerships.

Founded in 1908, Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. With nearly 14,000 employees, it is the largest private employer in the state, serving over 580,000 health plan members through Medicare Advantage, Medicaid, and Commercial plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.