Case Specialist

TEKsystems•Honolulu, HI

3d•$23 - $23•Onsite

About The Position

TEKsystems is seeking candidates who want to support a local healthcare organization in Hawaii. This role is responsible for investigating, researching, and resolving member appeals, grievances, complaints, and complex service issues. We are seeking candidates who are comfortable reviewing cases, conducting research, and taking the initiative to make outbound calls to members, providers, and internal business partners to gather information, provide updates, and help resolve issues. This is an on-site position located in Honolulu, Hawaii. The schedule is Monday through Friday from 8:00 AM to 5:00 PM, and free parking is provided. If you are interested in this opportunity, please apply, and one of our recruiters will reach out to discuss the position.

Requirements

Ability to work on-site five (5) days per week in Honolulu, Hawaii
Available to work Monday through Friday from 8:00 AM to 5:00 PM
Ability and willingness to make outbound phone 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
Ability to 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

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