Health Insurance Claims Specialist

TEKsystems•Honolulu, HI

3d•$23 - $23•Onsite

About The Position

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.

Requirements

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.

Nice To Haves

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.

Responsibilities

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.
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.