Care Manager - Disability & Behavioral Support

Bluestone-Physician-Services; Edina (MN); On-site; USD 69,000 - 80,000; Full time

Benefits offered by this job

Health Insurance

Disability Insurance

Health Savings Account (HSA)

Flexible Spending Account (FSA)

Retirement plan with matching

Paid holidays

Mileage reimbursement

Company device (laptop, cell phone)

Job summary

Bluestone Physician Services is hiring a Care Manager to support individuals with disabilities and complex behavioral health needs. This field-based role focuses on creating and executing comprehensive care plans, coordinating with primary clinicians, and keeping patients safely at home.

The position emphasizes 90% field-based direct patient care across Minnesota, Wisconsin, and Florida, with regular hours and a salary range of $68,500–$80,000 USD commensurate with experience.

Qualifications

• Experience working with individuals with disabilities or in residential care.
• Knowledge of behavioral health concepts and interventions.
• Strong communication and time-management skills.
• Proficient in using electronic health records and standard office software.

Responsibilities

• Develop and manage individualized care plans.
• Coordinate transitions and avoid unnecessary hospital utilization.
• Collaborate with MDs, NPs, and PAs for updated care strategies.
• Close care gaps to support value-based contracts and quality measures.
• Lead hospital and rehab discharge coordination to prevent readmissions.

Skills

Disability care

Behavioral health

Care coordination

EHR proficiency

Education

Bachelor's degree or higher

Licensed professional preferred

Tools

EHR systems

Job description

Care Manager - Disability & Behavioral Support

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:

Centered on individualized care management and 1:1 relationship building, the Care Manager drives comprehensive support for individuals with disabilities and persistent mental health conditions residing in group homes and assisted living settings. As the primary point of contact connecting individuals, families, and Primary Care Providers, the Care Manager ensures the seamless execution of a unified care plan while taking ownership of health outcomes, care gap closure, and the prevention of avoidable hospitalizations.

Schedule: Full time position, day shift hours, no evenings, weekends or holidays. Hours are 8am to 5pm Monday thru Thursday & 8am to 3pm on Fridays.
Location: This position is 90% field-based direct patient care, mainly throughout the Minnetonka, Edina, Bloomington areas.
Salary Range: $68,500 - $80,000. Salary commensurate with experience.

Responsibilities:

Care Coordination

• Care Plan Development: Develop and manage individualized, comprehensive care plans that align with organizational standards and program requirements. Support patients and families with honest advance care planning discussions and goal setting.
• Behavioral Health Management: Execute on CoCM model and implement specific behavioral health interventions.
• Clinical Partnership: Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.
• Gaps-in-Care & Utilization Management: Proactively identify and close clinical and documentation gaps to support Value-Based Care (VBC) contracts, including ACO initiatives. Take accountability for meeting quality measures, optimizing performance benchmarks, and preventing unnecessary utilization to effectively manage the Total Cost of Care (TCOC).

Operational Excellence & Coordination

• Transition Management: Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions.
• Acute Care Facilitation: Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions.
• Resource Optimization: Navigate and deploy community and organizational resources to support the patient’s ability to remain in their home. Ensure patients are aligned with the most optimal Bluestone care management program available.

Community, Patient & Family Support

• Education: Provide expert guidance to families and facility staff regarding behavioral and mental health concerns, and the Bluestone care model.
• Relationship Management: Serve as a point of care management contact, ensuring communication is streamlined and the patient and community experience is consistent.
• Care Model Adherence: Ensure all care management activities satisfy regulatory requirements.
• Field-Based Efficiency: Maintain high-visibility presence within assigned communities (90% field-based)

Qualifications :

Education/Certification/Experience

• 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.
• Experience in behavioral health preferred.

Knowledge/Skills/Abilities

• Proven experience working with individuals with disabilities and persistent mental health conditions in residential care environments
• Ability to work independently with excellent time-management and organizational skills
• Ability to maintain professional relationships members of the care team
• Ability to communicate effectively and professionally, both verbally and in writing, with diverse populations
• Advanced-level of computer proficiency with email, fax, word processing, spreadsheets, and databases
• Strong technical skills and experience with EHRs preferred
• 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 on (1) floating holiday
• Mileage reimbursement program for field employees
• Company sponsored cell phone, laptop and scrubs
• Regular business hours

Pay Transparency

$68,500 - $80,000 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.

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