Mary Glaser Email & Phone Number

Wisconsin Social Media Editor

Mendota Heights, Mn

The Director of Operations Audit and Appeals leads the quality audit program and Grievance and Appeals (G&A) Program for Anthem Dental. Primary duties include:• Develops and implements a vigorous Quality Assurance program that ensures pro-active risk mitigation and error detection. Responsible for vendor audits, operations call, claim, enrollment, G&A and related quality and risk adjustment activities to monitor efficiency and compliance with policies. Directs government audits and contract agreements as necessary.• Drives efficiencies in audit and G&A processes to ensure maximum return on activity and customer experience. Partners with operations analytical team to derive data-driven insights and trends based on data. Proactively communicates on QA and G&A and the value delivered by these teams. • Leads the planning, organizing, directing and evaluating the investigation, resolution, and response to client grievances and appeals, ensuring regulatory compliance requirements are met.• Develops operational budget as well as manages the departmental budget.• Maintains and coordinates staff activities so as to achieve departmental and corporate company goals in improving service to customers and assuring regulatory compliance and Company standards.• Directs analysis and development of strategies by achieving performance thresholds within budgetary guidelines for Audit and G&A. Engages business leaders in problem solving sessions to address quality issues prior to them becoming performance or compliance issues. • Contributes to and helps identify business issues, business risks and identifies business tasks for improvement of processes. Directs business needs and serves as liaison between business and IT regarding database systems.• Facilitates development, implements, and manages policies and procedures for the identification, collection and analysis of performance measurement data specific to the business segment under review.

Eagan, Mn

Eagan, Mn

• Ensure the audit scope and audit teams follow applicable guidelines for sampling, auditing and reporting performance. • Serve as liaison between business units, works directly with Clients and Partners on audit and accuracy related concerns. Participates in client contract rewrites. • Direct audit staff ensuring audit methodologies and reporting guidelines are implemented and met. • Lead performance audit process documentation program for claim, call and vendor audits, audit operations, and risk assessment activities. • Direct and monitor performance guarantee audit processes, performance guarantee reporting and process improvement. • Validate and coordinate compliance adherence in business units. • Assist with CMS/Public Program audits • Hire, train, coach, counsel, and evaluate performance of associates.

Eagan, Mn

Medicare Part D Pharmacy Operations • Manage COB, Third Party Liability, Negative Balance, Hospice, ESRD, and FWA.• Manage PBM and Client Medicare Part D website content. • Manage CMS attestations, Annual Data Validation audits, annual CMS PBP Bid Submissions and CMS Part D reporting validation and approval. • Facilitate the Administrative Law Judge (ALJ) hearings. • Work with PBM’s Care Management/Medication Therapy Management (MTM) team. • Served in a Lead role in the 2015 client implementation of Pharmacy Benefits Manager (PBM) transition.

Minneapolis, Mn

• Developed and implemented a National Claims Policies and Procedures manual and program focusing on consistency, compliance and best practices.• Developed and implemented a National Claims Quality Review program. • Facilitated the development of an extensive Claims System User Manual, a Reports User Guide and a comprehensive Claims Training Program. • Designed, tested and implemented the requirements for a web-based Claims Quality Review application that interfaced with claims systems for improved claims auditing with greater accuracy and a significant increase in user productivity. • Developed a claims system request for information (RFI), participated in the selected respondent interview process, developed the transition cost benefit analysis, providing recommendations to senior management. • Facilitated projects bridging several functional areas. • Worked with users in clarifying and mapping benefits to ensure accuracy in the requirements gathering and set up of client implementations. • Managed various project implementation activities including user documentation and maintenance of requirements and deliverables.• Gained expertise in HIPAA, DOL, Medicare Part D and Healthcare reform initiatives.• Worked with several PPO and PBM networks. • Served as Operations SME on Health Care Reform initiatives and operations liaison on ICD10 initiative.Regional Claims Operations Manager (2004 -2005)• Worked closely with seven Central region branches, implementing programs and written policies and procedures. Medical and Dental Claims Manager - Minneapolis Branch (2000 – 2003)• Managed staff of up to 55 claims and customer service staff including three Supervisors. • Account Management responsibilities for three Minneapolis branch clients, preparing for and attending monthly Trust meetings, presenting reports, and appeals. • Designed and implemented an on-line customer service call log application rolled out for use in the 26 Zenith branch locations.

Bloomington, Mn

• Oversaw the administration of several self-funded claims clients. • Managed a staff of 15.

Woodbury Mn

• Led claims operations for 120 self-funded clients.

Education record

Business Management Focus