Care Coordinator, RN (MSHO)

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

Benefits offered by this job

Health Insurance

Dental Insurance

Vision Materials Insurance

Company paid Life Insurance

Company paid Short and Long-term DISAB

Job summary

Bluestone Physician Services in Minnesota is seeking a Care Coordinator to empower seniors to navigate their healthcare journey and live independently. The role requires managing DHS and CMS requirements for MSHO/MSC+ members, and is hybrid, with travel to members' homes and facilities.

Schedule is full-time, 8:00 AM – 5:00 PM, with no evenings or weekends. Local community visits dominate (50-70%), with remote work the remainder; salary ranges from $65,000 to $75,000 depending on experience.

Qualifications

• Minnesota RN license or MN LSW/LISW/LMSW/LICSW; new grads encouraged to apply.
• One+ year experience with geriatric or disabled population in case management/care coordination.
• Valid driver's license.
• Hybrid/remote-capable role; willingness to travel locally.

Responsibilities

• Coordinate face-to-face visits with members and families.
• Manage Elderly Waiver program requirements.
• Conduct annual assessments including PCA assessments and living tools.
• Develop individualized care plans and goals.
• Connect members with community/state resources and services.
• Support safe home/community living and smooth transitions of care.
• Complete required documentation and collaborate with care teams.

Skills

Independent work

Private home office

Creative problem solving

Diversity awareness

Verbal communication

Interpersonal skills

English proficiency

Mission alignment

Education

Minnesota RN license

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

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 Brooklyn 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 :

• 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

• Comprehensive 6-month onboarding program
• 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
• Minnesota Registered Nurse license
• OR current MN Licensed Social Worker (LSW, LMSW, LISW, or LICSW) - 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

Bluestone Benefits :

• Health Insurance
• Dental Insurance
• Vision Materials Insurance
• Company paid Life Insurance
• Company paid Short and Long-term Disability
• Health Sav