Care Coordinator, LSW (MSHO)

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

Benefits offered by this job

Health Insurance

Disability (Short/Long-term)

Health Savings Account

Flexible Spending Account

Retirement match 4%

Paid holidays + floating day

Mileage reimbursement

Company laptop & phone

Scrubs provided

Regular business hours

Job summary

Bluestone Physician Services in Minnesota seeks a Care Coordinator to support DHS and CMS requirements for MSHO/MSC+ members. This hybrid role combines home visits with local travel, primarily in Woodbury, to help members access medical care, waiver services and community resources.

You’ll join a team delivering high-quality, patient-centered care, manage caseloads, and collaborate with care teams to ensure safe transitions and compliance.

Qualifications

• Current MN Licensed Social Worker (LSW/LMSW/LISW/LICSW) required.
• Minnesota RN license required.
• 1+ year geriatric or disabled population case management experience preferred.
• Valid driver’s license required.

Responsibilities

• Coordinate face-to-face visits within the assigned geographic area.
• Manage the Elderly Waiver program.
• Conduct annual PCA assessments and develop living tools for community members.
• Review health needs and develop individualized care plans.
• Connect members with community and state resources and services.
• Assist members to remain safely in their homes and communities.
• Complete required documentation for care coordination.
• Collaborate with medical teams to meet quality measures and utilization goals.
• Support transitions of care and ensure safe discharge planning.

Skills

Independent work

Problem-solving

Verbal communication

Interpersonal skills

English proficiency

Diversity awareness

Education

MN Licensed Social Worker

MN RN 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 Woodbury area (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

Pay Transparency

$65,000 - $75,000 USD