Customer Service Insurance

Lorella DeLeon

**** *. ***** ***** • Orange, CA *2868 • 714-***-**** • 714-***-****

Summary of Qualifications

Over 22 years of strong and diverse experience in the health insurance business. Senior Health Underwriter for Small Group Business, California licensed for Health, Accident and Disability. Experienced in all facets of group insurance including Stop Loss Reinsurance, customer service, underwriting, health education, analyzing, marketing, in-depth analysis, claims administration, utilization review, health insurance fraud and abuse, federal and state compliance laws. Over 20 years of Health Claims processing and auditing, expert in ICD9, CPT coding, Hospital and Rx coding, etc. Strong analytical skills, excellent communication skills, attention to detail extensive customer service experience working with clients as well as with brokers and general agents.

Work History

BEST Health Plans, Irvine, CA

9/07 to 4/30/2010

Senior Medical Underwriter, Small Group

Stop Loss Reinsurance Claims Auditor

Primary responsibilities included:

§ Pricing for various group health products, performing risk analysis and evaluating medical conditions of enrolling members

§ Utilizing knowledge of regulations to ensure compliance with applicable laws

§ Working closely with agents and brokers to agree upon the selling of the business

§ Providing educative support to our customers and consultants to help achieve their healthcare goals

§ Working with consulting services, marketing, new products, reviewing files for accuracy and working with carriers to make necessary corrections

§ As a Stop Loss Reinsurance Auditor responsibilities included processing, audit and investigation of all catastrophic claims submitted for reimbursement from the TPA to the Reinsurance Carrier. Working with the contracted Trustee and the guidelines of the regulatory requirements. Working with the general client to complete sound settlements accurately and in a timely manner.

Pacific Care/United Health Group, Cypress, CA

6/04 to 9/2007

Senior Underwriter, Small Group Underwriting

Primary responsibilities included:§ Responsible as team leader/supervisor for small team of underwriters of Small Group Business and checking daily work load, scheduling, performance and attendance. Reporting back to manager and director of the department. § Reviewing new applicant's experience and medical information to evaluate risk for overall Group Health and Life Insurance § Assessing data to set plan pricing for the group medical, dental, vision and life insurance premiums§ Checking regulations, industry factors, participation and other aspects of eligibility§ Working closely with actuaries, sales representatives, employers, and brokers

Pacific Life & Annuity, Irvine, CA

2000 to 2004

Small Group Underwriter

Responsibilities included:

New Business Underwriting

§ Verification of employer and employee eligibility on small group prospects, participation requirements and application of medical portability

§ Establishing final rate offer based on the medical conditions in the group and the applicable rate bands

§ Working closely with brokers and employers to present each group with the best rates possible while maintaining Pacific Life underwriting and quality standards.

Renewal underwriting

§ Adjusted standard renewal premium rates by reviewing the loss ratio in the prior year, and by identifying and evaluating risk criteria for individuals in each group

HCC Benefits, formally US Benefits, Costa Mesa, CA

1996 to 2000

Stop Loss Reinsurance Auditor

Responsibilities included:

§ Auditing of all catastrophic claims, analyzing the summary reports

§ Investigation of accident, workers compensation, disability, subrogation and third party claims

§ Working closely with providers, insurance companies, and investigative providers and administrators.

§ Negotiating with vendors for medical case management and or any other negotiating firm.

FHP Life Insurance, Costa Mesa, CA

1994-1996

Claims Examiner

Responsibilities included claims processing of medical, dental and life insurance claims. Included standard knowledge of examining, evaluation and pre-authorization and pre-screening of claims to administer appropriately for payment. Also worked as Claims team leader and trainer in the claims department.

Aetna Health plans, Loma Linda, CA

1987-1994

Responsibilities included processing of medical and dental claims, Evaluation and pre-activation of claims for payment and maintain effective customer service.

Education

Cypress College, California General Education

HIAA Insurance courses Certificate in Fundamentals

AHIP Insurance courses

Medical Portability classes

Health Insurance Nuts and Bolts

Insurance Company Operations

Insurance and Securities School of Southern California

Also a diverse number of Medical courses, Terminology, and Anatomy classes completed for the Health Education certificates

CA Licensed for Health Accident and Disability number 1066233

AALU Course work completed (101, 201 and 202)

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