Research Specialist



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Branch Information

Honolulu, HI - (USA) 737 Bishop Street Suite 122 HI Honolulu , HI 96813

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Job Description


Coordinates and facilitates contact with Employer Groups when the Research & Investigation (R&I) Division requires

clarification, documentation and/or verification for Confirmation of Eligibility (COE), Coordination of Benefits (COB),

Third-Party Liability (TPL), Subrogation, or other compliance-related functions. Assists with handling, investigating,

and responding to appeals regarding plan benefits, claims, eligibility, administrative processes, and precertification


Employer Group Liaison

· Acts as a point of contact between the Compliance Department and Employer Groups when information is

required for R&I related cases including but not limited to COE, COB, TPL, or Subrogation.

Appeals - Assists with the following:

· Researching and investigating formal appeals received by operational departments via written or electronic


· Researching and investigating complaints received through the Division of Insurance (DOI) or Department of


· Identifying whether or not a member or authorized representative qualifies for external review and/or arbitration.

· Working with arbitrators and external review organizations selected by the DOI to facilitate case reviews in

compliance with Federal and State Law.

· Gathering and summarizing information and recommendations from other departments for submission to Senior

Management and clients for decision-making.

· Drafting response letters to inquirers and complainants.

· Maintaining appeals soft-copy files and applicable logs.

· Sending final responses within the time frames stated in policies and procedures (P&P).

· Ensuring only approved internal and external documents are used.

· Complying with Federal, State and accreditation requirements as set forth in P&P.

Compliance Department Support and General

· Adheres to strict timelines in accordance with federal and state laws and accreditation to ensure compliance.

· Maintains files and documents, and provides support to the Department.

· Processes and distributes mail to applicable teammates.

· Identifies and processes straightforward TPL, COE and COB correspondence.

· Generates tracking log reports daily, monthly, or as needed to assist with timely processing.


High school diploma or GED is required. College degree; one year of experience in customer service, handling of

complaints and appeals, or a related area; and/or one year of experience in the healthcare industry is preferred.

License or Certification

None is required for this position

Knowledge, Skills, and Abilities

Qualification Required or Preferred

· Strong customer service, organizational, time management, and verbal and written

communication skills


· Detail-oriented, flexible, adaptable, and able to consistently meet timelines Required

· Able to multi-task and work independently and in a team environment Required

· Intermediate-level proficiency in Microsoft Word and Excel Required

· Basic-level proficiency in Microsoft Outlook Preferred

Physical Demands

The physical demands described here are representative of those an employee encounters while performing the

essential functions of this job.

· Able to remain in a stationary position and work on a computer for up to eight hours per workday.

· Able to converse on the telephone for up to four hours per workday.

· Frequently moving paper and hard copy files.

· Able to use standard office equipment such as computers, phones, photocopiers, filing cabinets, and fax