Care Coordinator, RN (MSHO)

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

Benefits offered by this job

Health Insurance

Short- and Long-term Disability

Health Savings Account

Flexible Spending Account

Retirement plan with 4% matching

9 paid holidays

Mileage reimbursement

Cell phone, laptop and scrubs

Regular business hours

Job summary

Bluestone Physician Services is seeking a Care Coordinator to empower Minnesota’s senior population to navigate their healthcare journey and live healthier, more independent lives.

The role involves managing DHS and CMS requirements for MSHO/MSC+ members in a hybrid arrangement, with local home visits and remote work. A Minnesota RN or licensed social worker with geriatric experience is preferred, and a valid driver’s license is required.

Qualifications

• Must hold Minnesota RN license or be a MN licensed social worker (LSW/LISW/LICSW).
• One+ year experience with geriatric or disabled populations in care coordination or related settings preferred.
• Must have a valid driver’s license.

Responsibilities

• Coordinate face-to-face visits within assigned geographic area.
• Manage Elderly Waiver and PCA assessments for community members.
• Develop individualized care plans and review health needs and goals.
• Connect members with community resources and services.
• Assist members to remain safely in their homes and communities.
• Document required information accurately and timely.
• Collaborate with care teams to ensure quality and utilization goals.
• Support safe discharges and follow-up planning.

Skills

Independent working

Verbal communication

Interpersonal skills

Geriatric care awareness

Customer service

Education

RN license in Minnesota

LSW/LISW/LicSW license in Minnesota

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 Maplewood and St. Paul 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

• 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
• 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.

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.