Case Resolution Specialist (Healthcare Appeals & Member Advocacy)

Make a Difference in Healthcare

Are you passionate about helping people navigate complex healthcare challenges? We're looking for a Case Resolution Specialist to join a team dedicated to investigating and resolving member concerns, appeals, grievances, and complex service issues. In this role, you'll serve as an advocate for members, helping ensure fair outcomes while working closely with healthcare professionals, operational teams, and stakeholders across the organization.

This is an excellent opportunity for someone with customer service, healthcare operations, insurance, case management, or call center environments who enjoys research, problem-solving, and making a meaningful impact.

What You'll Do

Investigate & Resolve Complex Cases

• Conduct detailed investigations into member appeals, grievances, complaints, and escalated service concerns.
• Review claims, authorizations, benefits, policies, call recordings, correspondence, and case histories to identify root causes and determine appropriate resolutions.
• Gather and analyze information from multiple departments and business partners to support case decisions.
• Research healthcare benefits, contractual language, and regulatory requirements related to member concerns.

Advocate for Members

• Act as a trusted resource and advocate by ensuring concerns are thoroughly investigated and resolved.
• Help members understand processes, benefits, and available options.
• Navigate sensitive situations with professionalism, empathy, and strong communication skills.

Drive Meaningful Outcomes

• Manage cases from intake through final resolution.
• Prepare written findings, resolution summaries, and correspondence.
• Coordinate corrective actions and collaborate with internal teams to improve member experiences.
• Identify recurring trends and recommend process improvements to prevent future issues.

Ensure Compliance & Quality

• Maintain accurate case documentation and investigation records.
• Support audit readiness and compliance with applicable regulations.
• Participate in quality reviews, reporting activities, and continuous improvement initiatives.

What We're Looking For

Required Experience

• Previous experience in customer service, healthcare operations, insurance, call center, claims, appeals, grievances, or administrative support.
• Strong critical thinking and analytical skills with the ability to investigate complex situations and determine appropriate solutions.
• Experience researching information, resolving issues, and making fact-based decisions.
• Excellent verbal and written communication skills.
• Ability to manage multiple priorities while maintaining attention to detail.

Preferred Qualifications

• Experience with healthcare payer or health insurance operations.
• Familiarity with membership appeals, grievances, claims, authorizations, or benefit administration.
• Case management experience.
• Knowledge of regulatory or compliance-driven environments.

Why This Role?

• Meaningful work that directly impacts the healthcare experience of members.
• Opportunity to solve complex problems and drive real change.
• Collaborative environment with cross-functional exposure.
• Career growth within healthcare operations, advocacy, compliance, and case management.
• Ideal for professionals who enjoy investigation, research, and helping others navigate challenging situations.

Top Skills for Success

✔ Healthcare Operations or Insurance Experience

✔ Customer Service & Member Support

✔ Appeals & Grievance Resolution

✔ Research & Problem Solving

✔ Critical Thinking & Investigation Skills

✔ Case Management & Documentation

✔ Strong Communication & Empathy

If you're looking for a role where you can combine healthcare knowledge, analytical thinking, and advocacy to make a difference every day, we'd love to hear from you.

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

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, o