NSA Arbitration & Claims Adjudication Specialist

APRIL SCOTT

Eastvale, California ***** · 951-***-****

*****.*******@*****.*** · linkedin.com/in/april-scott-0a774a13

Objective: To secure a challenging position in a company where I can apply my acquired skills and knowledge.

Summary: With over 20 years of experience working with major medical groups, I have developed proficiency in various software programs, case management, provider contracting, contract configuration, claims reimbursement and insurance verification. I have configured, built, managed and troubleshoot over several hundred contracts, Fee-schedules, and triplet configurations to ensure a timely completion. I am eager to share my knowledge and demonstrate my skills in a new role.

Experience

December 8, 2025 – Current

ARBITRATION SPECIALIST, NSA (NO SURPRISE ACT), HaloMD

Facilitates private out-of-court dispute resolution by managing the arbitration process, analyzing evidence, and helping parties reach binding agreements.

Reviewing, analyzing, and organizing relevant documents, testimony, and evidence to prepare for hearings.

Ensuring all actions, comply with legal standards, policies, and procedural rules (such as CMS guidelines for medical disputes).

Reviewing for coding errors (CPT, ICD-9) and managing, payor disputes. Ability to evaluate complex information to make sound, timely decisions.

Strong understanding of alternative dispute resolution (ADR) techniques, arbitration laws, and relevant industry regulations.

Proficiency in MS Office Suite (Word, Excel) and various case management portals

May 2024 – December 2025

BENEFIT VERIFICATION SPECIALIST, Cencora (Pharmaceutical Distribution)

Performs patient onboarding, benefit verification, prior authorization, and appeals processes, as needed, on behalf of patients and their physician to facilitate the process between the doctors’ office and pharmacy benefit manager (PBM) to triage and streamline prescription fulfillment.

Performs Data Entry and documentation, recording and maintaining accurate records of patient benefits information, including coverage levels, cost-sharing and provider options.

Using strong communicative skills, demonstrating problem solving techniques by identifying and resolving issues related to insurance coverage, and any potential written drug Adverse events.

Handled 15-25 cases a day of benefit verification and prior authorization follow ups via software system, Salesforce (I-Care), providing a resource to stay on task and measure productivity, ensuring department goals are met.

September 2022 – December 2022

TAPESTRY SR. BUSINESS CONTRACT CONFIGURATION ANALYST, Texas Childrens Hospital

Analyzed incoming requests through the Change Management Tracker (CMT) log and designed configuration solutions to meet business requirements.

Performed coding, contract, benefit, fee schedule, and claim editing rule configuration changes as needed.

Created testing scenarios to demonstrate efficiency of proposed configuration solutions.

Maintained thorough and concise documentation for all contract, benefit, fee schedules, and claim editing rule changes related to change control management or quality audit purposes.

Executed configuration changes accurately and timely to meet the department's standards for quality and service level agreements.

Assisted with the development of configuration standards and best practices.

Identified claims impacted by configuration changes through an EDI system and sent reports to the claims administration department for reprocessing.

Monitored pended claims and work queues to update appropriate systems.

Prioritized work and handled fluctuating volumes of tasks to meet deadlines and user needs of the Health Plan.

July 2014 – January 2022

SR. BUSINESS CONTRACT CONFIGURATION ANALYST, Kaiser Permanente

Certified in EPIC CORE training and proficient in EPIC AP training with deep knowledge of healthcare benefits, contract level information, and rate terms for building provider contracts and pricing in Tapestry.

Provided and managed updates on the tracking and progress of highly visible vendor contracts in build sessions to ensure implementation was within scope and consistent with management and shareholder deadlines. Troubleshooting build tickets through an inventory tracking system (MIRA).

Reviewed claims that were underpaid or overpriced and made reconfiguration and testing recommendations based on contractual agreements.

Conducted communication impact analysis and provided recommendations related to configuration design. Handled Command Center issues by resolving multiple tickets and identified impacts of benefit data and provider contract data.

Updated Contract Design Interpretation Document (CDID) according to contract exhibits and transmittals to ensure proper build in the Tapestry system.

Analyzed and interpreted configuration documents such as facility and professional transmittals, rate documents, and other artifacts for the team.

Managed the implementation of Tapestry for pre/post go-live activities with cross-functional teams to ensure accurate timeframes.

October 2012 – July 2014

PROVIDER CONTRACT SPECIALIST, ProMed Healthcare

Formulated and executed provider contracts for PCPs and specialists, and provided administrative expertise to credentialing services functions, including completing credentialing and re-credentialing applications for multiple providers.

Investigated, verified, tracked, and followed up on all responses from various sources.

Negotiated reimbursement rates for MOUs (Memorandums of Understanding) and LOAs (Letters of Agreement) for patient-specific contracts, PCPs, specialist, and ancillary providers contracts.

Presented the financial impact and cost-effectiveness of negotiated rates to the CEO and directors of the company.

Assisted the Claims Department with proper coding for reimbursement to providers based on their contract agreement.

June 2006 – October 2012

PROVIDER RELATIONS COORDINATOR, Monarch Healthcare

Participated in meetings to assess physician performance with HEDIS and Quality Measures, comparing their performance on a broad range of health issues.

Led Provider Satisfaction Workshop seminars with PCP and specialist office staff.

Wrote SOPs (Standards of Operation) for department functions, organized and managed projects, and drafted Excel grids for various projects, such as provider demographics, health plan and system clean-ups.

Trained provider offices on Monarch Healthcare software/program (Practice Connect) and assisted providers with any issues related to claims, authorizations, eligibility, monthly CAP checks, website issues, and creating reports through Excel.

Maintained the Provider Management System updates and assisted the Director as appointed.

Attended health fairs, office manager meetings, and general membership meetings for physicians.

Provided provider education on policy and procedure of Monarch's guidelines and their contract.

Education

MAY 1997

CERTIFICATE OF COMPLETION, North-West College

Graduated with a Certificate of Completion in: Medical Billing, Medical terminology, ICD-9 and CPT Coding, Insurance and Business Office Administration

JULY 1989

HIGH SCHOOL DIPLOMA, Valencia high school

Certifications

EPIC Tapestry Core and EPIC Tapestry AP Claims Certified

Activities

In addition to my professional experience, I have also been actively involved in leadership and volunteer roles within my church community. For the past several years, I have served as a women's group leader, organizing and facilitating regular meetings focused on spiritual growth and community building. I have also volunteered with various church programs, including community outreach initiatives and youth mentorship programs. Through these experiences, I have developed strong communication, organizational, and interpersonal skills, and have gained a deep appreciation for the importance of serving others and building strong, supportive communities.

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