STEPHANIE AVILES
Fidelis Care of New Jersey (Centene)
Morganville,NJ
1
Certification
14
years of professional experience
Results-driven BSN, RN and Healthcare Leader with extensive expertise leading Clinical Appeals, Grievances, Medical Fair Trials, Utilization Management, and regulatory compliance within Medicaid and managed care ecosystems. Recognized expert in healthcare payer operations, CMS and State Medicaid regulations, and NCQA standards. Proven track record of managing people leaders, analyzing operational trends, standardizing determination workflows, and spearheading 100% health plan representation in legal and medical fair trial proceedings. Adept at executing root-cause analyses, mitigating compliance risks, and driving continuous quality improvement across remote and hybrid team environments.
Work History
Manager of Medical Care Management (MLTSS)
1 Year 4 Months- Provide executive leadership, operational oversight, and strategic direction for large-scale clinical operations, directly supervising 3 Care Management Supervisors (People Leaders) and indirectly managing 45 RN Care Managers in a virtual/remote structure.
- Spearhead health plan representation across 100% of MLTSS medical fair trials and clinical appeals in New Jersey, partnering directly with the Medical Director to evaluate clinical evidence, present legal documentation, and negotiate settlements while protecting plan interests.
- Exercise market-wide utilization management and clinical oversight for Personal Care Assistant (PCA) assessments and adverse determination reviews, guaranteeing strict clinical justification and state/federal contract compliance.
- Analyze operational trends, monitor key performance indicators (KPIs), identify performance gaps, and execute Standard Operating Procedures (SOPs) that reduce turnaround times and maintain total audit readiness.
- Recruited, interviewed, and onboarded a high-performing specialized team of 11 MLTSS Care Managers, establishing standardized assessment protocols from the ground up.
Long Term Care Enrollment Specialist
1 Year 7 Months- Oversaw initial onboarding and clinical evaluations for a monthly caseload of 20–25 MLTSS members, ensuring full compliance with State Medicaid guidelines and state contract standards.
- Conducted comprehensive clinical assessments, developed individualized care plans, and resolved complex member grievances and care delivery barriers in collaboration with interdisciplinary teams.
- Served as New Hire Training Subject Matter Expert (SME) and mentor, standardizing workflows and ensuring
MLTSS RN Care Manager
1 Year 3 Months- Executed comprehensive clinical assessments, utilization reviews, and service authorization determinations for a high-volume caseload of 80–95 MLTSS members.
- Evaluated member appeals and clinical grievances, ensuring care decisions aligned with state contract mandates, quality metrics, and member safety protocols.
- Coordinated care across multidisciplinary teams, members, and families while adhering to managed care quality metrics and State Medicaid guidelines.
- Selected as New Employee Mentor and Subject Matter Expert to train incoming clinical staff on managed care workflows and regulatory compliance.
Operating Room / Charge Registered Nurse
1 Year 9 Months- Supervised surgical team workflows and clinical operations in the perioperative setting while maintaining strict adherence to AORN safety guidelines and facility standards.
- Circulated and scrubbed for complex surgical procedures, ensuring patient safety, infection control, and continuous multidisciplinary communication.
- Documented patient care using Electronic Health Record systems (Epic and Cerner), driving clinical quality assurance and operational standard adherence.
Labor & Delivery / Charge Registered Nurse
3 Years 2 Months- Led delivery room clinical operations, managed high-risk obstetrical care, and oversaw perioperative labor and delivery procedures.
- Served on the Unit-Based Council and Quality Improvement Committee; recognized with the Daisy Award for nursing excellence.
Lead Medical Assistant
4 Years 8 Months- Led daily clinical operations, interviewing, mentoring, and onboarding new support staff while driving process improvements and optimizing clinical workflows.
- Facilitated cross-functional collaboration with providers to ensure regulatory compliance and improve provider and patient experiences.
Education
Master of Science in Nursing (MSN) - Healthcare Leadership
- In Progress
Bachelor of Science in Nursing (BSN)
- Dean's List High Honors
- Magna Cum Laude
- GPA: 4.0
Registered Nurse Diploma
- Academic Excellence Award
- Trinitas Kellogg Scholarship Recipient
- Richard A. English Memorial Award
- Deans List High Honors
- Cum Laude
- Union County College
- GPA: 3.66
Skills
Appeals & Fair Trials: Clinical Appeals Processing
Medical Fair Trials & Defense
Legal Representation
Settlement Negotiation
Adverse Determination Reviews.
Managed Care Operations: Utilization Management (UM)
CMS & Medicaid Regulatory Requirements
NCQA & HEDIS Standards
Audit Readiness.
Leadership & People Mgmt: Direct Management of People Leaders (Supervisors)
Virtual/Remote Team Operations
Workforce Planning
PIPs.
Quality Assurance & SOPs: Operational Trend Analysis
Performance Metrics & KPI Tracking
SOP Optimization
Corrective Action Plans (CAPs).
Personal Information
- Title: BSN, RN | HEALTHCARE OPERATIONS & CLINICAL APPEALS LEADER
- ID Type: NJ RN License
- ID Number: #26NR19360400
Certification
Registered Nurse (RN): NJ State Board of Nursing (#26NR19360400), NJ Choice Assessor Certification: AVI2270
EDUCATION, HONORS & CERTIFICATIONS
Trinitas Kellogg Scholarship Recipient, Dean's List High Honors, Richard A. English Memorial Award, Academic Excellence Award
Timeline
Manager of Medical Care Management (MLTSS)
Fidelis Care of New Jersey (Centene)
06.2025 - CurrentRead More
Long Term Care Enrollment Specialist
Fidelis Care of New Jersey (Centene)
11.2023 - 06.2025Read More
MLTSS RN Care Manager
Wellcare Health Plans of New Jersey
08.2022 - 11.2023Read More
Operating Room / Charge Registered Nurse
Ocean Medical Center
11.2020 - 08.2022Read More
Labor & Delivery / Charge Registered Nurse
Atlantic Health System
09.2017 - 11.2020Read More
Lead Medical Assistant
Gastroenterology Consultants
01.2013 - 09.2017Read More
Chamberlain College of Nursing
Master of Science in Nursing (MSN) from Healthcare Leadership
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Chamberlain College of Nursing
Bachelor of Science in Nursing (BSN)
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Trinitas School of Nursing
Registered Nurse Diploma
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