Amber Grewal Email & Phone Number

Albuquerque, New Mexico, United States

Albuquerque, New Mexico Area

· Responsible for all provider network operations including development and strategies for health plan network comprised of 1300+ contracts and 5000+ practitioners across multiple product lines. Grew network 17% over 3 years in role. Providing leadership and direction for local market client including all provider activities including contracting and provider database management;· Collaborate with health plan leaders, government agencies and providers to review network performance including quality, costs, care gaps, risk adjustment gaps and develop improvement plans.· Provide input and data for RFP responses growing plan membership by 40% in 2019.· Developed and coordinated provider education for all product lines and provider relation plan/strategy to support network and company goals and objectives. · Ensure provider negotiations and contracts are managed in a way that is complaint with various state and federal regulatory agencies and company policy. Monitor provider contract performance to ensure service are provided according to contract terms. · Oversee the development and implementation of reimbursement strategies, including value-based purchasing agreements that are aligned with health plan objectives and also meet the demands of the provider community· Providing oversight and monitoring of network adequacy requirements within the established contracted networks· Monitoring department performance measures, and quality improvement activities

Albuquerque, New Mexico Area

· Managed Care Organization representative for state Medicaid and Human Services Department, providing input on topics influencing provider network, level of care guidelines and new program development. Collaborate to develop better integration with physical health network partners. · Supporting the provision of coaching and training for staff to ensure a continuous learning environment· Provide direction to determine companywide analytic reporting needs to support network performance and development. · Maintain ongoing internal and external communication with subordinates, providers, groups, regulatory bodies and corporate leadership. Monitoring staff on all internal operations including credentialing, contract administration, corporate policy and national accreditation standards. · Oversee document submission for internal /external mandated reporting, requests by legal counsel, regulatory bodies, fraud waste and abuse investigation and CMS, NCQA requirements. · Responsible for Network contract audits and reports to mitigate financial penalty and other risk· Developed content for successful Medicaid contract RFP and participated in contract readiness review · Demonstrated compliance with regulatory entities including NCQA, CMS and State Health Departments · Oversaw performance of department contractual and budgetary metrics

Albuquerque, New Mexico

Miami/Fort Lauderdale Area

· Key participant in strategy design addressing cost of care issues in assigned regions· Negotiated large physician groups and community mental health center contracts· Regional network credentialing committee liaison · Key role in development of department projects to improve metrics. IE. Improved claims processing and resolution workflow for new business implementation · Created training material and work plans to educate network providers on industry requirements· Advised on strategy to address provider concerns to improve relationships with MCO in state meetings· Maintained state regulatory requirements in system configurations and operations · Maintained adequate provider contracts and services in assigned territory that included Commercial, Medicaid and Medicare products· Assisted providers with contractual, credentialing and claims resolutions · Resolved member complaints and SIU investigations · Conducted on site training ansd audits of contracted providers

Master Of Healthcare Administration, Health/Health Care Administration/Management

Bachelor Of Science (B.S.), Physiology, General