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.

Key Responsibilities:

Respond to patient inquiries via phone, written correspondence, Pres Online, E-Business, chat, and in-person
• Assist with scheduling appointments, referrals, messaging, and updating patient demographics
• Ensure service excellence and a positive member experience in every interaction
• Maintain accurate records and documentation in compliance with policies

• 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.

• Responds to questions or issues from PHP members and providers about insurance benefits, coverage, or premiums (Medicaid, Commercial, IBAC, Medicare) with regard to: eligibility and demographic changes; ID card request and issuance; PCP assignments and changes; eligibility, terms and conditions, with respective benefit plan.
• Respond to incoming calls routed through skill-based technology to meet quality standards and performance measurements. Is ready to take calls at the scheduled time, and spends the appropriate amount of time taking calls throughout their shift to resolve contacts on initial encounter. Conducts outbound calls as required and meets established quality/quantity guidelines supporting PHS/PHP/PMG initiatives and/or programs.
• Develop and maintain positive customer or partner relationships. Acts as member/patient advocate in dealing with practitioners, employer groups, and brokers. Maintains prescribed standards of quality in all research, customer and partner contacts/service functions and promotes customer satisfaction/loyalty through quality contact and timeliness of responses, achieves quality audit results as required.
• Participates and represents PHS/PHP in outreach events to include, but not limited to enrollment fairs, site visits, health fairs, job fairs, Member Focus Groups, Provider Information Sessions, Provider Focus Groups and ANOC meetings held throughout the state.
• Assists in the development of documentation of process and procedures into functional process improvements to enhance overall level of service to our customers and partners. Uses the Improvement model, identifies patterns in call inquiries/grievances, conducts root cause analysis in resubmitted and adjusted claims and reports to management team.
• Researches inquiries/special projects as requested and responds to customer, partner or other PHS/PHP business units to ensure accuracy of benefit interpretation with results of research and resolution and within required timelines. Responses to customer or partners to be done using Microsoft Word, Excel or similar databases when appropriate. Uses available documentation such as D.A.R.T., Provider Manual, Pres Online, and Policies and Procedures to analyze and provide accurate and consistent information and benefit interpretation.
• Participates as an effective and active team member both individually and in a team environment. Participates in a value-added manner as a team member to internal teams as well as other process improvement teams (i.e. QCC) and initiatives.
• Record all calls, mail, email, faxes, walk-in encounters, etc. in appropriate databases to provide meaningful, accurate data for analysis and reporting.
• Assist in coordinating (when necessary) meetings with customers or partners for training, contracting, and reporting.
• Perform other functions as required.

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.