Health Insurance Case Resolution Specialist

TEKsystems; Honolulu (HI); On-site; USD 32,000 - 34,000; Full time

Benefits offered by this job

Medical benefits

401(k) plan

Life Insurance

PTO

Job summary

TEKsystems in Honolulu, HI is seeking a Case Resolution Specialist to investigate member appeals, grievances, and service issues within a healthcare payer environment. The on-site role emphasizes thorough case reviews, root-cause analysis, and timely, accurate resolutions in collaboration with providers and internal teams.

The ideal candidate has strong customer service experience, knowledge of healthcare payer processes, and solid investigative and communication skills to manage complex cases

Qualifications

• Experience in customer service, healthcare operations, call center environments, or administrative support roles.
• Knowledge of healthcare insurance, health plan operations, and payer-related processes.
• Experience handling appeals, grievances, complaints, escalated cases, or member issue resolution.
• Strong critical thinking, investigative, and problem-solving abilities.
• Ability to conduct thorough research and analyze complex information to determine appropriate resolutions.
• Excellent verbal and written communication skills.
• Strong organizational skills and attention to detail.
• Ability to manage multiple priorities and deadlines in a fast-paced environment.
• Proficiency with case management systems and standard business software applications.
• Ability to work independently while collaborating effectively with cross-functional teams.

Responsibilities

• Investigate member appeals, grievances, complaints, and escalated service issues.
• Review claims, authorizations, benefits, correspondence, policies, procedures, call recordings, and member histories to identify root causes and determine appropriate resolutions.
• Gather and analyze information from multiple departments, including Claims, Customer Service, Clinical Operations, Utilization Management, Care Management, Provider Services, and Pharmacy.
• Research health plan benefits, contractual language, and regulatory requirements related to member concerns.
• Identify recurring trends, operational issues, and opportunities for process improvement.
• Manage assigned case inventory from intake through final resolution.
• Evaluate facts, evidence, policies, and regulatory requirements to determine appropriate outcomes.
• Prepare case findings, resolution summaries, and member communications.
• Ensure all cases are completed within established turnaround times and service-level agreements.
• Escalate complex, sensitive, or high-risk cases when appropriate.
• Coordinate corrective actions with internal business partners to address and resolve member concerns.
• Communicate directly with members, providers, and authorized representatives to gather information and explain case outcomes.
• Provide clear, professional explanations regarding appeal, grievance, and complaint processes.
• Manage difficult or emotionally charged situations with empathy, professionalism, and effective communication.
• Deliver status updates throughout the investigation and resolution process.
• Serve as the primary point of contact for assigned cases.
• Review and process appeals and grievance cases according to organizational policies and regulatory requirements.
• Ensure complete, accurate, and audit-ready documentation.
• Prepare case files and supporting materials for leadership, compliance, or clinical review as needed.
• Collaborate with quality, compliance, and operational teams to ensure regulatory adherence and process consistency.
• Maintain detailed case notes and investigation records within case management systems.
• Document findings, determinations, and supporting rationale.
• Track case outcomes, trends, root causes, and resolution effectiveness.
• Participate in quality reviews, audits, and regulatory reporting activities.
• Recommend process improvements and operational enhancements based on case findings and trend analysis.

Skills

Customer service experience

Healthcare payer knowledge

Analytical thinking

Problem-solving

Communication skills

Organizational skills

Independent work

Cross-functional collaboration

Case management systems

Tools

Case management systems

Job description

Case Resolution Specialist

*Location:* On-site Honolulu, HI

*Employment Type:* Full-Time

Position Summary The Case Resolution Specialist is responsible for investigating, researching, and resolving member appeals, grievances, complaints, and complex service issues within a healthcare insurance environment. This role serves as a key advocate for members by conducting thorough case reviews, analyzing healthcare benefits and claims information, identifying root causes, and coordinating appropriate resolutions while ensuring compliance with regulatory requirements and organizational standards.

The ideal candidate combines strong customer service experience, healthcare payer knowledge, analytical thinking, and problem-solving skills to manage complex cases from intake through resolution. This position works closely with members, providers, and cross-functional business partners to deliver timely, accurate, and member-focused outcomes.

Key Responsibilities Case Investigation & Research

• Conduct comprehensive investigations of member appeals, grievances, complaints, and escalated service issues.
• Review claims, authorizations, benefits, correspondence, policies, procedures, call recordings, and member histories to identify root causes and determine appropriate resolutions.
• Gather and analyze information from multiple departments, including Claims, Customer Service, Clinical Operations, Utilization Management, Care Management, Provider Services, and Pharmacy.
• Research health plan benefits, contractual language, and regulatory requirements related to member concerns.
• Identify recurring trends, operational issues, and opportunities for process improvement.

Case Resolution

• Manage assigned case inventory from intake through final resolution.
• Evaluate facts, evidence, policies, and regulatory requirements to determine appropriate outcomes.
• Prepare case findings, resolution summaries, and member communications.
• Ensure all cases are completed within established turnaround times and service-level agreements.
• Escalate complex, sensitive, or high-risk cases when appropriate.
• Coordinate corrective actions with internal business partners to address and resolve member concerns.

Member & Provider Communication

• Communicate directly with members, providers, and authorized representatives to gather information and explain case outcomes.
• Provide clear, professional explanations regarding appeal, grievance, and complaint processes.
• Manage difficult or emotionally charged situations with empathy, professionalism, and effective communication.
• Deliver status updates throughout the investigation and resolution process.
• Serve as the primary point of contact for assigned cases.

Appeals & Grievance Administration

• Review and process appeals and grievance cases according to organizational policies and regulatory requirements.
• Ensure complete, accurate, and audit-ready documentation.
• Prepare case files and supporting materials for leadership, compliance, or clinical review as needed.
• Collaborate with quality, compliance, and operational teams to ensure regulatory adherence and process consistency.

Documentation & Reporting

• Maintain detailed case notes and investigation records within case management systems.
• Document findings, determinations, and supporting rationale.
• Track case outcomes, trends, root causes, and resolution effectiveness.
• Participate in quality reviews, audits, and regulatory reporting activities.
• Recommend process improvements and operational enhancements based on case findings and trend analysis.

Required Qualifications

• Previous experience in customer service, healthcare operations, call center environments, or administrative support roles.
• Knowledge of healthcare insurance, health plan operations, and payer-related processes.
• Experience handling appeals, grievances, complaints, escalated cases, or member issue resolution.
• Strong critical thinking, investigative, and problem-solving abilities.
• Ability to conduct thorough research and analyze complex information to determine appropriate resolutions.
• Excellent verbal and written communication skills.
• Strong organizational skills and attention to detail.
• Ability to manage multiple priorities and deadlines in a fast-paced environment.
• Proficiency with case management systems and standard business software applications.
• Ability to work independently while collaborating effectively with cross-functional teams.

Preferred Qualifications

• Experience with healthcare membership appeals and grievance processes.
• Case management experience.
• Knowledge of regulatory requirements related to healthcare plans and member services.
• Experience identifying operational trends and recommending process improvements.
• Familiarity with multiple healthcare lines of business.

Ideal Candidate The successful candidate is a compassionate and detail-oriented professional who serves as a strong advocate for members while balancing regulatory, operational, and business requirements. They possess strong investigative skills, excel at resolving complex issues, and can effectively collaborate with stakeholders across the organization to deliver positive member outcomes and drive continuous improvement.

Work Environment

• On-site work environment
• Collaborative team setting
• Complimentary parking available
• Opportunity to make a direct impact on member satisfaction, advocacy, and case resolution outcomes in a healthcare insurance setting.

*Job Type & Location*

This is a Contract position based out of Honolulu, HI.

*Pay and Benefits*The pay range for this position is $23.33 - $23.33/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

*Workplace Type*This is a fully onsite position in Honolulu,HI.

*Application Deadline*This position is anticipated to close on Aug 28, 2026.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.