David Whetstone
Las Vegas,NV
Summary
I'm an analytic thinker with a passion for improving operations and solving problems with several years in the healthcare insurance industry. I've helped enhance efficiency, ensure compliance, and use insights to support better outcomes. I enjoy digging into data, spotting trends, and finding solutions that make a real impact. My goal is to always simplify tasks and help teams work smarter.
Overview
11
11
years of professional experience
Work History
Content Moderation Representative
TELUS Digital
07.2024 - 12.2024
- Identified content trends as they emerged, and used that information to adjust moderator strategies, helping to avoid potential problems.
- Offered feedback in a helpful, approachable way to improve how users interacted with the platform, while ensuring compliance within the rules and guidelines.
- Worked alongside various teams, helping to simplify the moderation process and improve overall efficiency, always looking for ways to enhance the workflow.
- Ensured platform quality by personally reviewing content shared by users, aligning it with community standards and legal requirements, so the network remained safe and welcoming for everyone.
Customer Account Specialist
North Hollywood Ice Company
07.2017 - 03.2024
- Managed a high volume of customer accounts, processing orders and coordinating timely deliveries for businesses and events.
- Worked directly with the customers to process payments, resolve outstanding balances, and maintain up-to-date financial records.
- Developed lasting customer relationships by delivering reliable service, resulting in continued business satisfaction.
- Acted as the main point of contact for all accounts, providing personalized support tailored to each customer’s needs.
Appeals and Grievances Coordinator
Health Net, LLC (a Centene Corporation)
01.2017 - 07.2017
- Investigated and resolved grievances and appeals submitted by members enrolled in Medi-Cal, ensuring compliance with state and federal regulations.
- Reviewed and analyzed case details, including medical records, provider notes, and correspondence from members to deliver accurate resolutions.
- Drafted clear and concise response letters to members, outlining the rationale for decisions and providing a detailed explanation of outcomes.
- Collaborated with different departments, such as legal, customer service, and claims departments, to resolve complex cases, and guarantee a thorough approach to member care.
- Processed an average of 7+ cases daily, consistently meeting and surpassing daily targets for case closure.
Appeals and Grievances Analyst
Elevance Health (formerly Anthem Blue Cross)
08.2015 - 05.2016
- Collaborated with other departments, such as legal, customer service and claims departments to resolve complex cases and ensure a thorough approach to member care.
- Investigated and resolved grievances and appeals for large employer-sponsored Administrative Services Only (ASO) plans within National Accounts.
- Reviewed and analyzed case details, including medical records, provider notes, and member correspondence to determine accurate resolutions.
- Drafted clear and concise response letters to members, outlining the rationale for decisions and providing a detailed explanation of outcomes.
- Processed an average of 5+ cases daily, consistently meeting and surpassing daily targets for case closure.
Customer Service Representative I-III
Elevance Health (formerly Anthem Blue Cross)
09.2013 - 08.2015
- Responded to a high volume of incoming calls from providers for members enrolled in large group plans (100 or more employees), addressing inquiries related to benefits, claims, coverage, and policy details.
- Ensured all interactions complied with HIPAA and other regulatory standards to protect member confidentiality and privacy.
- Met or exceeded established KPIs, including call handle time, first call resolution, customer satisfaction, quality assurance scores.
- Progressed through three CSR tiers due to demonstrated expertise in claims resolution, provider relations, and 100% accuracy.
Education
California State University-Chico
Chico, CA06.2011
Los Angeles Pierce College
Woodland Hills, CA07.2010
High School Diploma -
El Camino Real High School
Woodland Hills06.2007
Skills
- HIPAA & PHI Compliance
- Claims Investigation & Resolution
- Appeals & Grievances
- Healthcare Policy & Regulatory Compliance
- Call Center Operations
- Healthcare Terminology
- Multi-system Navigation
- Customer Relationship Management
- Policy Interpretation
Timeline
Content Moderation Representative
TELUS Digital
07.2024 - 12.2024
Customer Account Specialist
North Hollywood Ice Company
07.2017 - 03.2024
Appeals and Grievances Coordinator
Health Net, LLC (a Centene Corporation)
01.2017 - 07.2017
Appeals and Grievances Analyst
Elevance Health (formerly Anthem Blue Cross)
08.2015 - 05.2016
Customer Service Representative I-III
Elevance Health (formerly Anthem Blue Cross)
09.2013 - 08.2015
California State University-Chico
Los Angeles Pierce College
High School Diploma -
El Camino Real High School