Care Coordinator, LSW (MSHO)

Bluestone-Physician-Services; Brooklyn Center (MN); Hybrid; USD 65,000 - 75,000; Full time

Benefits offered by this job

Health Insurance

Short & Long-term Disability

Health Savings Account

Flexible Spending Account

Retirement plan with 4% match

9 paid holidays + 1 floating holiday

Mileage reimbursement

Company laptop & scrubs

Job summary

Bluestone Physician Services seeks a Care Coordinator to help Minnesota seniors navigate healthcare, access essential services, and remain independent at home. You will work on DHS and CMS requirements for MSHO/MSC+ members, with travel for home visits.

The role is hybrid, combining remote work with local community visits, and offers a 65k-75k salary plus benefits. No evenings or weekends required, and 8-5/8-3 schedule.

Qualifications

• Current MN Licensed Social Worker (LSW/LMSW/LISW/LICSW) or equivalent.
• Minnesota RN license is required.
• Experience with geriatric or disabled populations in care coordination preferred.
• Must have a valid driver’s license.

Responsibilities

• Coordinate face-to-face visits with members.
• Manage Elderly Waiver caseload.
• Conduct annual PCA assessments and create living tools for members in assisted living.
• Develop individualized care plans based on health needs and goals.
• Link members to community and state resources and services.
• Support safe in-home and community living transitions.

Skills

Empathy & communication

Independent work

Verbal communication

Customer service

English proficiency

Education

MN Licensed Social Worker (LSW/LMSW/LISW/LICSW)

Minnesota RN license

Geriatric care coordination experience

Driver's license

Job description

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 — Primarily the Brooklen Center and Minneapolis areas (50–70% local community visits; 30–50% remote work from home)

Salary Range: $65,000 - $75,000, commensurate with experience.

Responsibilities

As a Care Coordinator, you will manage member caseloads within your assigned geographic area. Key responsibilities include:

• 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

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 or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Pay Transparency

$65,000 - $75,000 USD