Care Manager - Disability & Behavioral Health (Field-Based)

Bluestone Physician Services; Minnesota; On-site; USD 69,000 - 80,000; Full time

Job summary

Bluestone Physician Services seeks a Care Manager to provide individualized, 1:1 care management for people with disabilities and chronic mental health conditions in group homes and assisted living settings. You will be the primary contact connecting patients, families, and Primary Care Providers to execute unified care plans and improve outcomes.

The role emphasizes health outcomes, care gap closure, and prevention of avoidable hospitalizations, with 90% field-based direct patient care across

Qualifications

• Bachelor's degree or higher preferred.
• Licensed personnel preferred - LPN, RN, or Social Worker.
• 3-5 years of experience in value-based care, population health, case management, care coordination and/or discharge planning.

Responsibilities

• Care Coordination: Develop and manage individualized, comprehensive care plans and support families with advance care planning.
• Transition Management: Lead hospital and rehab discharge coordination to prevent 30-day readmissions.
• Acute Care Facilitation: Coordinate on-site acute visits and telehealth for timely interventions.
• Resource Optimization: Connect patients with community resources to stay in their home settings.
• Community, Patient & Family Support: Provide guidance to families and facility staff on behavioral health and Bluestone care model.
• Education: Educate families and facility staff on the care model and best practices.
• Relationship Management: Serve as primary care management contact with streamlined communication.
• Care Model Integrity: Ensure activities meet regulatory requirements and program standards.
• Field-Based Efficiency: Maintain high-visibility field presence in assigned communities (90%).

Job description

Bluestone Physician Services seeks a Care Manager to provide individualized, 1:1 care management for people with disabilities and chronic mental health conditions in group homes and assisted living settings. You will be the primary contact connecting patients, families, and Primary Care Providers to execute unified care plans and improve outcomes.

The role emphasizes health outcomes, care gap closure, and prevention of avoidable hospitalizations, with 90% field-based direct patient care across