Claims Specialist

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

About the role

This is a fully on-site, contract position based in Honolulu, Hawaii. The schedule is Monday through Friday from 8:00 AM to 5:00 PM, with free parking provided.

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

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
• Experience with case management systems is preferred

Pay

The pay range for this position is $23.33 - $23.33 per hour. Individual compensation offered within this range will depend on qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Benefits

Eligibility requirements apply to some benefits and may depend on job classification and length of employment. Benefits are subject to change and may include:

• Medical, dental, and vision insurance
• Critical Illness, Accident, and Hospital coverage
• 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)