Merlyne Calipso-Vil
North Miami Beach,FL
Summary
Professional seeking a position with a growth oriented institution offering eventual advancement. I want an opportunity to apply my leadership skills to an innovative and educational environment where they will make a significant impact in an atmosphere in which new ideas are welcome and decision making is required.
Overview
19
19
years of professional experience
1
1
Certification
Work History
Patient Access Services
Jackson Health System (North)
08.2023 - 07.2024
- Emergency room patient registration
- Collection of patient insurance for medical services
- Collection of service fee and insurance copayments
- Obtaining insurance authorization for medical services to assist billing
- Provide customer service to patients, family and friends
- Ensure patient names, date of birth is accurate for patient safety
- Safeguard patient privacy and adhering to HIPPA laws.
Auto Adjuster
State Farm (Prime Consulting Group)
Greeley, CO
09.2021 - 11.2021
- Investigate Auto Claims for liability decision
- Confirm policy active for the date of loss
- Claim review and documenting claim notes in file
- Outgoing and incoming calls from customers
- Complete contacts will all parties involved.
Remote Claims Associate
State Farm (Pilot Catastrophe Services)
Mobile, AL
08.2021 - 09.2021
- Assist with incoming call and provide customer service
- Review and document mail according to guidelines
- Claim notes on all claims reviewed and/or addressed
- Forwarding documents to Claims Specialist once reviewed per guidelines.
Remote Property Claims Adjuster
State Farm (Pilot Catastrophe Services)
Mobile, AL
08.2020 - 10.2020
- Investigate Property Damage Claims due to Hurricane/Wind damages
- Review individual Policy and coverage and determine coverages applicable
- Complete Contact with insureds to communicate policy coverages
- Review property damage estimates in accordance to the loss
- Compile the appropriate file documents
- Complete the applicable claim notes and all communication
- Provide initial payment and supplements based on coverage.
Remote Commercial PIP Adjuster
Assurant (The Best IRS)
Phoenix , AZ
09.2019 - 10.2019
- Investigate commercial auto claims for PIP and Medpay Coverage
- Contact with insured and claimant to determine coverage based on individual policies throughout the state of Florida
- Review of medical bills, payments for services and seek closure
- Conducted interviews, maintained telephone communication with insureds, claimants, and witnesses; consults police and hospital records; and inspects property damage to determine extent of company's liability, varying method of investigation according to type of insurance
- Prepare claim notes to confirm coverage decisions concerning the policy, the insured and the attorney involved.
Auto Claims Adjuster
State Farm (The Best IRS)
Winterhaven, FL
08.2018 - 12.2018
- Investigate claims against insurance or other companies for personal, casualty, property loss, damages and attempts to effect out-of-court settlement with claimant
- Conducted interviews, maintained telephone communication with insureds, claimants, and witnesses; consults police and hospital records; and inspects property damage to determine extent of company's liability, varying method of investigation according to type of insurance
- Prepared report of findings and negotiated settlements with insureds and/or claimants.
PD/Liability Adjuster
State Farm (Prime Consultant Group)
Greeley, CO
05.2016 - 10.2016
- Investigate, negotiate, evaluate and settle moderate to complex Personal Injury Protection claims to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio
- Pay and process claims within designated authority level; adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation
- Maintain claim files such as records of settled claims and an inventory of claims requiring detailed analysis
- Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures
- Contact or interview claimants, witnesses, and insureds to get additional information.
PIP/MED PAY Adjuster
State Farm (The Best IRS)
Eagan, MN
06.2015 - 12.2015
- Investigate, negotiate, evaluate and settle moderate to complex Personal Injury Protection claims to effect fair and prompt disposal of cases and to contribute to a reduced loss ratio
- Pay and process claims within designated authority level; adjust reserves or provide reserve recommendations to ensure that reserve activities are consistent with corporate policies
- Enter claim payments, reserves and new claims on computer system, inputting concise yet sufficient file documentation
- Maintain claim files such as records of settled claims and an inventory of claims requiring detailed analysis
- Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures
- Contact or interview claimants, witnesses, and insureds to get additional information.
PD Adjuster
State Farm (The Best IRS)
Frederick, MD
07.2014 - 12.2014
- Examined vehicle damage to determine liability in of 1st & 3rd party auto insurance claims in the following jurisdictions: MD, DE, NC, VA and WV
- Interviewed claimants and witnesses for investigative purposes
- Prepared investigative reports and reported findings
- Determined insurance coverage by analyzing claims records
- Gathered evidence to support claims in court
- Negotiated fair settlements with internal and external parties
- Analyzed carefully each fact to detect patterns of insurance fraud
- Reviewed and paid estimates invoices for rental, body shop repairs and other invoices
- Determined liability in collision losses using witness and involved parties’ statements and police reports
- Reviewed claims for total loss when necessary.
Litigation
Universal Property & Casualty
Fort Lauderdale, FL
09.2013 - 12.2013
- Investigate claims against insurance or other companies for personal, casualty, property loss, damages and attempts to effect out-of-court settlement with claimant
- Conducted interviews, maintained telephone communication with insureds, claimants and witnesses; consults police and hospital records; and inspects property damage to determine extent of company's liability, varying method of investigation according to type of insurance
- Prepared report of findings and negotiated settlements with insureds and/or claimants
- Provided recommendation of litigation by legal department when settlement could not be negotiated.
PIP/Med Pay Adjuster
Windhaven (The Best IRS)
Doral, FL
06.2011 - 12.2011
- Performed in an investigative role to determine coverage for claims assigned for PIP coverage
- Authorization of payments within the prescribed limits of coverage
- Personal contacts with policyholders, claimants, agents, witnesses, police and fire departments, state and county fraud personnel, special investigators, attorneys, expert witnesses and members of the medical profession
- Conducted interviews, maintained telephone communication with insureds, claimants and witnesses; consults police and hospital records; and inspects property damage to determine extent of company's liability, varying method of investigation according to type of insurance
- Including recorded statements of all parties involved.
Licensed Claims Adjuster (PIP/Med Pay)
Farmers Insurance Group
Davie, FL
01.2007 - 01.2010
- Performed in an investigative role to determine coverage for claims assigned
- Reviewed damages in order to negotiate and settle claims
- Authorization of payments within the prescribed limits of coverage
- Facilitator of continued training for the PIP/Med Pay department staff
- Personal contacts with policyholders, claimants, agents, witnesses, police and fire departments, state and county fraud personnel, special investigators, attorneys, expert witnesses and members of the medical profession.
Licensed Claims Adjuster (PIP/Med Pay)
Allstate Insurance Co
Sunrise, FL
01.2006 - 01.2007
- Investigations of medical claims for injuries aroused from auto accidents
- Determine and reports on subrogation claims
- Complete investigations to support the Special Investigation Unit
- Monitor and injury claims to rule out insurance fraud.
Education
M.B.A. - International Business
St. Thomas University
Miami, Florida01.2007
B.A. - Organizational Leadership
St. Thomas University
Miami, Florida01.2004
A.A. - Criminal Justice
Miami Dade College
Miami, Florida01.2004
Skills
- Excellent writing and verbal communication skills
- Strong research and investigation skills
- Excellent interpersonal skills
- Excellent sound judgment, analytical, negotiation, and decision-making skills
- Multitasking and Organization
- Claims Investigation
- Best Practices Implementation
Certification
- Senior Claim Law Associate (SCLA) – American Educational Institute.
Timeline
Patient Access Services
Jackson Health System (North)
08.2023 - 07.2024
Auto Adjuster
State Farm (Prime Consulting Group)
09.2021 - 11.2021
Remote Claims Associate
State Farm (Pilot Catastrophe Services)
08.2021 - 09.2021
Remote Property Claims Adjuster
State Farm (Pilot Catastrophe Services)
08.2020 - 10.2020
Remote Commercial PIP Adjuster
Assurant (The Best IRS)
09.2019 - 10.2019
Auto Claims Adjuster
State Farm (The Best IRS)
08.2018 - 12.2018
PD/Liability Adjuster
State Farm (Prime Consultant Group)
05.2016 - 10.2016
PIP/MED PAY Adjuster
State Farm (The Best IRS)
06.2015 - 12.2015
PD Adjuster
State Farm (The Best IRS)
07.2014 - 12.2014
Litigation
Universal Property & Casualty
09.2013 - 12.2013
PIP/Med Pay Adjuster
Windhaven (The Best IRS)
06.2011 - 12.2011
Licensed Claims Adjuster (PIP/Med Pay)
Farmers Insurance Group
01.2007 - 01.2010
Licensed Claims Adjuster (PIP/Med Pay)
Allstate Insurance Co
01.2006 - 01.2007
M.B.A. - International Business
St. Thomas University
B.A. - Organizational Leadership
St. Thomas University
A.A. - Criminal Justice
Miami Dade College
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