PCSC Health Plan Services Representative I-ABQ
 Presbyterian Healthcare Services | |
life insurance
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 United States, New Mexico, Albuquerque | |
| 1100 Central Avenue Southeast (Show on map) | |
 Aug 15, 2026 | |
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Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237Compensation Pay Range: Minimum Offer $16.79 Maximum Offer $27.67 Now Hiring: PCSC Health Plan Services Representative I-ABQSummary: Responsible for providing customer service for members and providers in all PHP benefit plans. Ensure callers receive service excellence when responding to telephone, written, Pres Online, E-Business, chat and in person inquires. Type of Opportunity: Full time Job Exempt: No Job is based: Reverend Hugh Cooper Administrative Center Work Shift: Days (United States of America)Responsibilities: *Resolve questions, issues or concerns from PHP plan members, authorized individuals, and providers regarding insurance benefits, coverage, eligibility, terms, and conditions. Provide information about the respective benefit plan, including details about premiums, medical claims research and resolution, accumulators, coordination of benefits, changes in demographics, and requests for ID cards or correspondence.*Assist members in accessing care by facilitating changes to their Primary Care Physician, locating contracted providers within the plan's network, and scheduling appointments. *Assist with prior authorization submissions and their statuses. *Resolve member and provider escalations by educating them on correct processes and facilitating research with other departments. Address any plan needs or concerns, intake appeals and grievances and provide status updates *Professionally and calmly manage crisis calls from members who could be experiencing medical or behavioral crisis and utilize critical thinking skills to effectively get support to the member in real time. . *Manage offline activities, which may include researching and resolving unique member or provider circumstances, reconciling Medicaid travel credit card transactions, Medicaid travel coordination, utilizing Secure Messaging, handling chat messages, addressing in-person walk-ins, and managing email correspondence *Trained to resolve member and provider issues across multiple lines of business (Medicare, Turquoise Care, Commercial, etc.) to effectively maintain Service Level Agreements (SLAs), ensuring that all performance metrics standards (NCQA, CMS Compliance, and Regulatory, Soft Skills, Evaluations, Post Call Surveys) are consistently met. Continuously updates knowledge on a diverse range of processes to guarantee accuracy and efficiency in operations. *Responsible to take calls at their scheduled times and remain productive during their shift to ensure they can answer all incoming calls. They will uphold their commitment to follow up with members and providers by completing outbound calls as necessary. Additionally, they will adhere to the established quality guidelines that support PHS, PHP, or PMG initiatives and programs. *Build and nurture positive relationships with customers and partners. Serve as an advocate for members and patients when interacting with practitioners, employer groups, and brokers. Ensure that all customer and partner contacts and service functions meet established quality standards. Promote customer satisfaction and loyalty by providing timely and high-quality responses, and strive to achieve the required quality audit results. *Participates in and represents PHP/PHS at outreach events, including but not limited to enrollment fairs, site visits, health fairs, job fairs, Member Focus Groups, Provider Information Sessions, Provider Focus Groups, and Medicare Annual Notice Of Change meetings held throughout the state. *Researches inquiries by responding to customers, partners, or other PHS/PHP business units to ensure accurate benefit interpretation. This includes providing research results and resolutions within the required timelines. Responses to customers or partners are prepared using Microsoft Word, Excel, or similar databases when appropriate. Available resources such as DART, Wiki, ProviderConnect, MemberConnect, PresNet, phs.org, and Policies and Procedures and other resources is utilized to analyze and ensure the information and benefit interpretations are accurate and consistent. *Utilize various systems and communication channels to ensure a consistent healthcare and customer experience. This includes using telecommunication platforms, claims processing software, behavioral health, medical, and dental portals in collaboration with different vendors, as well as billing, payment, and enrollment software, along with any other relevant systems. *Capable of managing multiple tasks with competing priorities by using effective problem-solving skills and available resources. *Contributes effectively both individually and as part of a team. Engages in a value-added manner with internal teams and other process improvement initiatives. *Records all customer service events, including calls, mail, emails, faxes, and walk-in encounters, in the appropriate databases to ensure meaningful and accurate data is available for analysis and reporting. *Performs special projects as assigned including service recovery outbound calls. *Performs other functions and duties as required. Qualifications: *High school/GED diploma*1 year office/business experience *Call Center experience preferred. All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits. Wellness Why work at Presbyterian? About Presbyterian Healthcare Services Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. We're Determined to Support New Mexico's Well-Being | Presbyterian Healthcare Services | |