Care Coordinator, LSW (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. Our success is only possible through the hard work of our employees who bring our core values of Dedication, Excellence, Collaboration and Caring to life every day. Bluestone has been named to the Star Tribune's Top Workplace list for the 14th year in a row! Bluestone also achieved Top Workplace USA 2021-2026! 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 , empowering Minnesota’s senior population to navigate their healthcare journey and live healthier, more independent lives. In this role, you’ll manage Department of Human Services (DHS) and Center for Medicare/Medicaid Services (CMS) requirements for MSHO/MSC+ members. This is a hybrid position where you’ll work from home while traveling locally to meet directly with members in their homes and assisted living facilities, helping them access vital medical care, waiver services, and community resources. Schedule: Full-time, 8:00 AM – 5:00 PM (Monday through Thursday) and 8:00 AM – 3:00 PM (Friday). No evenings, weekends, holidays, or on-call requirements. Location: Hybrid — Rogers, Minnesota area (50–70% local community visits; 30–50% remote work from home) Salary Range: $65,000 - $75,000, 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 Help members remain safely in their homes and communities 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 Additional Benefits of Joining Bluestone's Care Coordination Team Dedicated preceptor support Ongoing mentoring and coaching Continuing education and professional development Collaborative managers who work alongside you Experienced documentation auditors focused on education and quality Qualifications Education/Certification/Experience Current MN Licensed Social Worker (LSW, LMSW, LISW, or LICSW) - New grads encouraged to apply! ORMinnesota Registered Nurse license 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 Bluestone Benefits Health 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 Mileage reimbursement program for field employees Company sponsored cell phone, laptop and scrubs Regular business hours Pay Transparency $65,000 - $75,000 USD As set forth in Bluestone Physician Services’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law. #J-18808-Ljbffr Bluestone Physician Services