Geriatric Care Manager

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 Focused on the 1:1 relationship and patient management. The Geriatric Care Manager is a specialized, field-based care team member responsible for supporting the management ofcomplex and chronically ill patients and behavioral health conditions within senior living communities. Serving as theprimary link between the patient, the family, and the Primary Care Provider, this role ensures a single, unified care plan isexecuted. The Care Manager is accountable for optimizing patient outcomes, closing gaps in care, and reducingunnecessary hospitalizations for a complex, chronically ill population. 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 This position is 90% field-based direct patient care, mainly throughout the Forest Lake and Hugo areas. Salary Range $68,500 - $80,000. Salary commensurate with experience. Responsibilities Care Coordination Care Plan Development: Develop and manage individualized, comprehensive care plans that align with organizational standards and program requirements. Support patients and families with honest advance care planning discussions and goal setting. Behavioral Health Management: Execute on CoCM model and implement specific behavioral health interventions. Clinical Partnership: Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status. Gaps-in-Care & Utilization Management: Proactively identify and close clinical and documentation gaps to support Value-Based Care (VBC) contracts, including ACO initiatives. Take accountability for meeting quality measures, optimizing performance benchmarks, and preventing unnecessary utilization to effectively manage the Total Cost of Care (TCOC). Operational Excellence & Coordination Transition Management: Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions. Acute Care Facilitation: Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions. Resource Optimization: Navigate and deploy community and organizational resources to support the patient’s ability to remain in their home. Ensure patients are aligned with the most optimal Bluestone care management program available. Community, Patient & Family Support Education : Provide expert guidance to families and facility staff regarding dementia, mental health concerns, and the Bluestone care model. Relationship Management : Serve as a point of care management contact, ensuring communication is streamlined and the patient and community experience is consistent. Care Model Adherence : Ensure all care management activities satisfy regulatory requirements. Field-Based Efficiency : Maintain high-visibility presence within assigned communities (90% field-based) Qualifications Education/Certification/Experience Bachelor's degree or higher preferred. Licensed personnel preferred - LPN, RN, or Social Worker. Strong preference for candidates with 3–5 years of direct clinical experience in geriatric care, acute care, post-acute care, or health system discharge planning. Experience in behavioral health preferred. Knowledge/Skills/Abilities Knowledge and experience with Assisted Living and Memory Care communities Ability to work independently with excellent time-management and organizational skills Ability to maintain professional relationships members of the care team Ability to communicate effectively and professionally, both verbally and in writing, with diverse populations Advanced-level of computer proficiency with email, fax, word processing, spreadsheets, and databases Strong technical skills and experience with EHRs preferred 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 on (1) floating holiday Mileage reimbursement program for field employees Company sponsored cell phone, laptop and scrubs Regular business hours Pay Transparency

$68,500 - $80,000 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. If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows: A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability. A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval and air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Select... #J-18808-Ljbffr Bluestone Physician Services