Summary: The Workforce Group, a LEMOINE company, is seeking a Claims Reviewer – Claims and Appeals to support disaster recovery operations in New Mexico. In this critical role, you will evaluate, review, and adjudicate claims and appeals, ensuring compliance with federal regulations, program policies, and internal procedures. You will work closely with inspectors, planners, estimators, SMEs, and administrative staff to provide accurate claims determinations, resolve appeals, and support communities affected by disasters.
Location: Hermit Peak New Mexico and surrounding areas
Duties and Responsibilities:
- Review and evaluate disaster recovery claims, supporting adjudication of both initial claims and appeals in accordance with federal regulations and program guidance.
- Work with claimants, designated claimant representatives, or Navigators to assist claimants in formulating a strategy for obtaining necessary supporting documentation to complete a Proof of Loss and meet other requirements specified by the COR/TM.
- Follow established guidance, policies, and procedures to provide objective evaluation of claims and produce detailed reports with recommendations to an Authorizing Official.
- Provide claimant support, identify all potential losses for compensation, and use standard rate calculators to maximize compensation within the limits of applicable law.
- Ensure claims compensation is not duplicated with benefits provided by other programs, including but not limited to Public Assistance Program, Individual Assistance Program, and other applicable programs.
- Assist in appeals processing as appeals analysts by completing document retrieval, reviewing appeals cases, developing appeals recommendations, and supporting the Appeals, Audits, and Arbitration functions of the Claims Office.
- Assess documentation, including inspection reports, cost estimates, repair plans, and other supporting materials, to determine allowable claims.
- Communicate with claimants, program staff, FEMA personnel, and other stakeholders to clarify claims decisions and provide guidance on appeals.
- Collaborate with inspectors, planners, estimators, and SMEs to verify information, resolve discrepancies, and ensure accurate claims determinations.
- Maintain and manage claims and appeals files, ensuring documentation is complete, organized, and compliant with regulatory requirements.
- Identify trends, recurring issues, or potential risk areas within claims and appeals to support process improvement.
- Utilize claims management software, databases, and tracking systems to document claims, appeals decisions, and communications.
- Prepare reports, summaries, and recommendations to support program evaluation, leadership decision-making, and compliance audits.
- Review QC claims when needed ensuring they notify the Claims Reviewer of items requiring rework, additional documentation, or updated compensation determinations. QC reviews shall follow regulations, policy, and program guidance.
- Ensure adherence to quality standards, deadlines, and program guidelines for all claims and appeals processes.
- Perform other job-related duties as assigned.
Education and Experience / Qualifications: A High School Diploma or equivalent is required; advanced certifications in claims management, insurance, or disaster recovery are highly preferred. A minimum of 5 years of experience in claims processing, appeals management, insurance, or disaster recovery program operations is required. Must have a NFIP (National Flood Insurance Program) certification. Experience supporting federal programs, disaster recovery operations, or FEMA claims processes is highly preferred.
- Strong understanding of federal regulations, policy guidance, and claims adjudication standards is required.
- Strong attention to detail, organizational skills, and the ability to manage multiple claims/appeals under tight deadlines is required.
- Excellent written and oral communication skills to accurately document findings and communicate with claimants and program staff is required.
- Strong analytical, organizational, and attention-to-detail skills to evaluate complex documentation are required.
- Strong problem-solving skills and the ability to identify and escalate risks or compliance issues is required.
- The ability to manage multiple priorities, deadlines, and appeals cases simultaneously is required.
- Strong problem-solving, conflict resolution, and decision-making skills are required.
- Proficiency in claims management software, databases, and technology tools is highly preferred.
ABOUT US
The Workforce Group a LEMOINE company is a Great Place to Work® Certified company.We are a team of dedicated professionals that pull together to meet the needs of communities partnering with federal, state, and local governments.
We are an equal opportunity/affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, national origin, age, protected veteran status, or disability status.
