Presbyterian Healthcare Services

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at Presbyterian Healthcare Services

Posted: 9/17/2020
Job Reference #: 16239
Keywords: technical, system

Job Description

Requisition ID
Health Plan Service Operations
Default: Location : City
Location : Name
9201 San Mateo Blvd NE Albuquerque, NM 87113-2227
Default: Location : State/Province (Full Name)
New Mexico


Job Description
Type of Opportunity: Full Time
FTE: 1.000000
Exempt: No
Work Schedule: Days

Work independently with all claims areas to provide technical claims analysis, responsible for resolving complex claims problems, fielding general questions, and direction and assistance to Configuration and IS departments; Functions as claims liaison between claims areas and other functional areas within PHP.

The ideal candidate must have at least 3 years experience in health insurance claims processing and/or related operational areas within a health insurance managed care environment demonstrating a strong knowledge of claims processing.


* Serve as liaison between Claims Operations and other functional areas of business.
* Under supervision, submit claims issues/problems by Service Request across functional areas of business (System Configuration, IS, Provider Network Management, Marketing, Clinical Operations, etc.).Analyze policies and procedures to determine changes needed and develop written changes.
* Shares knowledge and information about issues and solutions across business areas.
* Participates in testing of new system configuration to ensure accuracy of Operations policies and procedures and training materials.
* Assists with ensuring policies and procedures are in compliance with CMS, DOI, and NCQA and HEDIS requirements.
* Perform claims adjustments and claims processing as necessary and other functions as required.
* Obtain approval across product and functional lines of business to ensure consistency in our business practices.
* Acts as the claims resource person to answer questions internally or externally for all functional areas of business with minimal assistance
* Participate in benefit contract review to ensure consistency between the benefit contracts and Operations activities.
* Obtain accurate pricing for claims when necessary.
* Perform other duties and functions as required.


High School Diploma required and two to three years college level courses/Associates Degree/Diploma or Bachelors Degree in business administration or related field preferred. At least 3 years experience in health insurance claims processing and/or related operational areas within a health insurance managed care environment demonstrating a strong knowledge of claims processing

Prefer experience with Facets and HRP is a plus!

Competencies and skills:

* Planning and coordinating organizational change
* Anticipating & Addressing Customer Needs
* Educating Employees, Customers & Transferring Knowledge
* Functioning as an Effective Contingent Member
* Diagnosing & Resolving Problems
* Acquiring & Applying Superior Skills to achieve Quality Outcomes
* Functioning as an Effective Team Member


Benefits are effective day-one (for .45 FTE and above) and include:

  • Competitive salaries
  • Full medical, dental and vision insurance
  • Flexible spending accounts (FSAs)
  • Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  • Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

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



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