Loretta Summers

• Conduct and participate in credentialing and privileging activities
• Determine the practitioner's eligibility for membership/participation to ensure compliance with accreditation and regulatory standards
• Distribute and track all credentialing application packets requested by MFA department contacts for prospective practitioners
• Utilize the CAQH database to retrieve and analyze practitioner applications and supporting documentation for completeness according to accreditation and regulatory standards
• Inform practitioner and MFA department contacts of the application status, and resolve pending issues, including the collection of additional information
• Ensure compliance with accreditation and regulatory standards by processing initial and reappointment applications for eligible practitioners
• Compile, evaluate, and present practitioner files for committee review to ensure compliance with accreditation and regulatory standards
• Complete practitioners' enrollment applications into DC Medicaid, Maryland Medicaid, Virginia Medicaid, Medicare, and Tricare
• Ensure the provider numbers for the governmental payors are loaded in the billing system to ensure the timely release of claims to the payors
• Complete the revalidation/re-enrollment application into DC Medicaid, Maryland Medicaid, Virginia Medicaid, and Medicare for each practitioner every five years
• Update the medical/professional licenses that are about to expire with DC Medicaid, Maryland Medicaid, and Virginia Medicaid

• Managed multiple priorities effectively, resulting in the on-time completion of credentialing tasks for numerous providers simultaneously.
• Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
• Monitors the initial credentialing, recredentialing and expirable process for all network providers and delegated providers.
  • Assists with delegated credentialing audits; conducts internal file audits.
  • Coordinates with the provider to complete the privilege process, including any additional documentation, verifications, references and applications necessary.
  • Assists in the development, planning and operational management of the credentialing/privilege delineation and reappointment program to ensure the program's integrity.
  Responsible for tracking all expirables -i.e. Licensure's, BLS, DEA, etc.
  Facilitated the quarterly Credentialing Committee meetings.
• Developed strong relationships with external organizations, leading to increased cooperation during verification processes.
• Prepared records for site visits and file audits.

• Served as a resource for departmental staff by maintaining a thorough understanding of current trends and best practices in the credentialing field.
• Contributed to risk management initiatives by monitoring expiring licenses, certifications, and insurances, notifying providers of renewal requirements in a timely manner.
• Assisted in maintaining accreditation status by preparing necessary reports and materials for site visits and audits.
• Streamlined the credentialing process by implementing an efficient tracking system for medical staff applications.
• Tracked expiration dates on documents and communicated with appropriate staff to avoid late filing.
• Maintained accurate files, records and credentialing documents in well-maintained databases using MSOW software.

• Elevated client satisfaction rates through prompt resolution of any provider-related issues or concerns that arose during the credentialing process.
• Increased efficiency in data management by implementing a user-friendly database system for storing provider information.
• Assisted with special projects as needed, demonstrating adaptability and commitment to the success of the organization.
• Enrolled providers and Medicaid, Medicare, and private insurance plans.
• Conducted periodic compliance audits and reviews to identify areas of improvement.

• Collaborated with healthcare providers to gather necessary information for accurate credentialing decisions.
• Conducted audits of provider files, ensuring all necessary documents were up-to-date and compliant with regulatory requirements.
• Conducted primary source verifications such as background checks and board certifications.
• Safeguarded confidential provider information by adhering to strict data privacy regulations and company policies.

• Received and evaluated applications to look for missing and inaccurate information.
• Provided exceptional customer service to both internal and external stakeholders, addressing inquiries promptly and professionally.
• Managed credentialing files with strict adherence to confidentiality and privacy laws, ensuring secure handling of sensitive information.
• Addressed and resolved discrepancies in provider documentation, maintaining high level of data integrity.
• Coordinated with multiple departments to ensure compliance with healthcare regulations, maintaining accreditation standards.

• Troubleshot complex issues using root-cause analysis techniques, leading to effective problem-solving strategies that minimized recurrence instances.
• Reduced downtime through proactive monitoring of network health and addressing issues promptly.
• Conducted and coordinated outreach calls to prospective network providers to secure credentialing/contract information
• Imaged/data entered documents and information in support of the credentialing and contracting processes.
• Provided issue resolution and complex trouble shooting for providers.

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• Supported the transitioning of ARNG providers with initial entry credentialing, maintenance of credentialing and privileging, and suppo1t the Centralized Credentials Privileging Board's review of completed credentials and privileged files.
• Supported the credentialing process of assessing and reviewing the qualifications of the health care practitioner. The process includes review of the licensure, training and education of skilled care providers (e.g. Physicians, Dentists, Family Nurse Practitioners and Physician Assistants) and assures their clinical competency and that they maintain regulatory compliance in their scope of practice
• .• Entered provider data according to established department standards.

• Fostered a positive work environment through active participation in team meetings, collaborating on strategies to improve departmental performance.
• Maintained accurate files, records and credentialing documents in well-maintained databases using Cactus.
• Collaborated with department heads to develop a comprehensive credentialing policy, ensuring compliance with industry standards.
• Minimized potential legal complications by ensuring adherence to federal and state regulations governing healthcare practitioners'' licensure and certification requirements.
• Obtained NPI numbers for providers and facilities and updated existing profiles.
• Kept informed regarding pending industry changes, trends or best practices.
• Assisted with development of compliance objectives and strategies.
• Improved turnaround times for processing credentials by diligently reviewing and verifying provider eligibility.
• Worked closely with practitioners to help each obtain privileges at assigned healthcare facilities

• Ensured compliance with relevant regulatory requirements regarding data storage, security, and privacy by staying updated on changing laws and guidelines.
• Collaborated with IT department to develop and maintain secure, user-friendly databases.
• Optimized database performance by conducting regular audits and updates.
• Facilitated seamless data migration during system upgrades and transitions.