Honolulu Appeals & Claims Specialist

TEKsystems; Honolulu (HI); On-site; USD 27,000 - 38,000; Full time

Job summary

TEKsystems is seeking candidates to support a local healthcare organization in Hawaii. The role involves investigating, researching, and resolving member appeals, grievances, complaints, and complex service issues.

The on-site position is in Honolulu, with a Monday–Friday schedule and free parking. Responsibilities include reviewing claims and policies, gathering information from multiple internal departments, managing cases from review to resolution, and drafting findings and communications.

Qualifications

• On-site five days per week in Honolulu, Hawaii
• Monday–Friday 8:00 AM–5:00 PM
• Outbound calls to members, providers, and internal business partners to gather information, resolve issues, and provide case updates
• Strong critical thinking, problem-solving, and investigative skills
• Research complex issues and analyze information from multiple sources
• Excellent written and verbal communication skills
• Strong organizational skills and attention to detail
• Experience documenting and maintaining accurate case records
• Ability to manage sensitive situations with professionalism and empathy
• Experience with case management systems is preferred

Responsibilities

• Investigate member appeals, grievances, complaints, and escalated service issues
• Review claims, authorizations, benefits, policies, correspondence, and member histories to determine root causes and appropriate resolutions
• Research plan benefits, contractual language, and regulatory requirements related to member concerns
• Gather and analyze information from internal departments including Claims, Customer Service, Clinical Operations, Provider Services, Care Management, and Pharmacy
• Manage assigned cases from initial review through final resolution
• Analyze findings and determine appropriate outcomes based on policies, evidence, and regulatory requirements
• Draft case findings, resolution summaries, and member communications
• Conduct outreach to members, authorized representatives, and providers to obtain information and provide updates
• Explain appeal and grievance processes in a professional and easy-to-understand manner
• Maintain detailed case notes, investigation records, and supporting documentation within the case management system
• Ensure all case activities meet regulatory requirements, organizational standards, and required turnaround times
• Escalate high-risk, sensitive, or complex cases when necessary
• Track case outcomes, identify trends, and recommend process improvements
• Support audits, quality reviews, regulatory reporting activities, and continuous improvement initiatives
• Collaborate with internal business partners to coordinate resolutions and improve the member experience

Skills

On-site work

Outbound calls

Investigation skills

Case research

Communication skills

Documentation

Regulatory awareness

Collaboration

Tools

Case management systems

Job description

TEKsystems is seeking candidates to support a local healthcare organization in Hawaii. The role involves investigating, researching, and resolving member appeals, grievances, complaints, and complex service issues.

The on-site position is in Honolulu, with a Monday–Friday schedule and free parking. Responsibilities include reviewing claims and policies, gathering information from multiple internal departments, managing cases from review to resolution, and drafting findings and communications.