Melissa Ayala
Bangor,PA
Summary
Dedicated Workers Compensation Adjuster with proven expertise in managing claims and ensuring timely processing. Strong communication skills facilitate effective collaboration with all parties, enhancing customer service and claim resolution. Committed to continuous improvement and quick mastery of new skills, contributing to operational efficiency.
Detail-oriented professional driven to resolve claims fairly while representing interests of employer. Conducts thorough and informed investigations, precisely evaluates losses and negotiates settlements that satisfy diverse parties. Builds and maintains professional and productive relationships and works to understand potentially conflicting points of view.
Overview
1
1
Certification
4
4
years of professional experience
Work History
Medical Only Claims Specialist
PRG Insurance
05.2026 - 09.2026
- Reviewed insurance claims in the midwest, ensuring accuracy and adherence to policy compliance to facilitate timely processing.
- Managed claim caseload, adhering to company standards to maintain quality and meet service expectations.
- Determined liability, compensability, and placed reserves.
- Contacted clients to gather necessary claim documents, streamlining the claims process for improved turnaround.
- Documented claim activities in detail to maintain accurate records. and conversation details in organized files.
Workers Compensation Adjuster
Corvel Corp
Norristown, PA
10.2023 - Current
- Reviewed and analyzed workers' compensation claims to determine eligibility for benefits
- Investigated and assessed validity of workers' compensation claims, ensuring compliance with regulations and safeguarding the integrity of the claims process.
- Investigated and gathered necessary information, such as medical records and witness statements, to evaluate the validity of claims
- Conducted interviews with injured employees, employers, witnesses, or healthcare providers to obtain additional information for claim evaluation
- Maintained proactive communication with employees, medical providers, and insurance carriers, ensuring clarity and collaboration throughout the claims process.
- Developed strong relationships with healthcare providers/medical facilities for efficient exchange of information/documentation
- Assisted injured employees in obtaining appropriate medical treatment and follow-up care.
- Organized and managed comprehensive documentation for workers' compensation claims, facilitating accurate processing and timely decision-making.
- Coordinated workers' compensation claims, ensuring accuracy and timely processing.
- Documented claims in full, entering payments, reserves and new information.
- Determined validity of payment authorization on previously investigated claims by carefully reviewing documentation.
- Adjusted reserves or provided reserve recommendations.
- Ensured compliance with federal, state, and local regulations pertaining to workers' compensation.
Claims Specialist Property Complex
State Farm Insurance
Bethlehem, P.A
06.2022 - 03.2023
- Consistently deliver a remarkable customer experience through handling property claims
- Investigates, evaluates, negotiates, and settles auto claims in an assigned area to include verification of coverage, legal liability and extent of damage to persons and property, which may require contact by telephone, email, correspondence, in-person or other electronic media
- Applies knowledge of policies, procedures, laws, statutes and insurance regulations when determining coverage, liability, and property damage
- Evaluated additional investigation needs to resolve claims effectively
- Utilized electronic resources for efficient claim handling
- Collaborated with and instructed claim associates to enhance team capabilities
- State Farm is a large group of insurance and financial services companies in the United States. Website: https://www.statefarm.com
Education
High School Diploma -
Hempstead High School
09-2009
Skills
- Workers' compensation claims
- Claims analysis
- Medical coding
- CPT coding
- ICD coding
- Liability assessment
- Anatomical knowledge
- Microsoft Excel
- Microsoft Word
- Workload management
- Organizational ability
- Analytical thinking
- Effective communication
- Medical office experience
- Liability assessment
Certification
- Independent Adjuster NY Motor Vehicle No-Fault & Workers Comp Health Service Charges
Timeline
Medical Only Claims Specialist
PRG Insurance
05.2026 - 09.2026
Workers Compensation Adjuster
Corvel Corp
10.2023 - Current
Claims Specialist Property Complex
State Farm Insurance
06.2022 - 03.2023
High School Diploma -
Hempstead High School