Care Coordinator, RN (MSHO)

Bluestone delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Our unique, robust model of care goes beyond primary care services — our multidisciplinary care teams collaborate with patients, their families and other healthcare providers to deliver care that is preventative, proactive and tailored to their unique needs. Using an evidence-based approach focused on quality care management and data-driven medical decisions, Bluestone care teams collaborate to manage patients’ chronic conditions, address social determinants of health, manage transitions to and from inpatient settings, provide behavioral health support and more. Under our model of care, Bluestone patients experienced 21% fewer ER visits, 36% fewer hospitalizations and 41% fewer hospital readmissions compared to patients with similar conditions and complexities over the same time period. Our care teams travel directly to patients who reside in Assisted Living, Memory Care and Group Home communities throughout Minnesota, Wisconsin and Florida and are supported by clinical operations and administrative colleagues who work remotely or at our corporate offices in Stillwater, Minnesota, and Tampa, Florida. Bluestone has been named to the Star Tribune's Top Workplace list for the 13th year in a row! Bluestone also achieved Top Workplace USA 2021-2025! In 2022, Bluestone Accountable Care Organization (ACO) was the best performing ACO in the country as measured by the overall savings per Medicare beneficiary. Position Overview Join our team as a Care Coordinator where you will work with the senior population managing Department of Human Services (DHS) and Center for Medicare/Medicaid Services (CMS) required activities for Minnesota Senior Health Options (MSHO/MSC+) members living in the community and assisted living facilities. In this position, you will work from home, but regularly travel your local area to serve the needs of your members and your community. Schedule: Full time position, day shift hours, no evenings, weekends or holidays. Hours are 8am to 5pm Monday thru Thursday & 8am to 3pm on Fridays. Location: ~50-70% travel throughout the White Bear Lake and Lino Lakes areas and ~30-50% remote work. Salary Range: $65,000 - $75,000. Salary commensurate with experience. Responsibilities Coordinating face-to-face visits Managing the Elderly Waiver Conducting annual assessments including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in Assisted Livings Reviewing current health needs, identifying goals, and developing individualized care plans Helping connect members with community and state resources and services Completing required documentation Collaborating with medical care teams to ensure health care quality measures are met and use utilization management tools to meet value-based goals Supporting members during transitions of care as well as collaborating with their care team to ensure a safe discharge and follow up plan Education, Certification & Experience Current Minnesota Registered Nurse license OR current MN Licensed Social Worker (new grads encouraged to apply) One or more years of experience working with the geriatric or certified disabled population in case management/care coordination, Home Care, Group Homes, Nursing Homes, TCU or Assisted Living settings preferred Must have a valid driver’s license Knowledge, Skills & Abilities Ability to work independently Access to a private and compliant home office space Creative problem-solving skills Appreciation for working with diverse populations Proven ability to communicate effectively with strong verbal skills Excellent interpersonal and customer service skills Demonstrated compatibility with Bluestone’s mission and operating philosophies Demonstrated ability to read, write, speak, and understand the English language Benefits Health Insurance Dental Insurance Vision Materials Insurance Company paid Life Insurance Company paid Short and Long-term Disability Health Savings Account (with employer contribution) Flexible Spending Account (FSA) Retirement plan with 4% matching contributions Nine (9) paid holidays for office closures plus one (1) floating holiday Three weeks (15 Days) Paid Time Off (PTO) Mileage reimbursement program for field employees Company sponsored cell phone, laptop and scrubs Regular business hours #J-18808-Ljbffr