Care Manager - Disability & Behavioral Support

Bluestone

Maple Grove (MN)

On-site

USD 69,000 - 80,000

Full time

11 days ago

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Benefits offered by this job

Health Insurance

Dental Insurance

Vision Materials Insurance

Company paid Life Insurance

Disability insurance

Retirement plan with 4% matching

Job summary

Bluestone seeks a Care Manager for Minnesota with a focus on individuals with disabilities and persistent mental health conditions. This 90% field-based role involves coordinating care plans, collaborating with physicians, and ensuring seamless transitions from inpatient settings to home care.

The position requires a Bachelor's degree and experience in value-based care/care coordination; licensed personnel are preferred.

Qualifications

Bachelor's degree or higher preferred; licensed personnel preferred (LPN, RN, or Social Worker).
Knowledge/Skills: care coordination, behavioral health familiarity, field-based work, and effective communication.

Responsibilities

Care coordination and development of individualized care plans.
Lead transitions from hospital/rehab to home to prevent readmissions.
Collaborate with MDs, NPs, and PAs to update care strategies.
Educate families and facility staff on Bluestone care model and behavioral health.

Skills

Disabilities care

Time management

Professional communication

EHR experience

Team collaboration

Education

Bachelor's degree

Licensed clinician preferred

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

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 Maple Grove and Rogers, MN 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 Integrity

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

Knowledge and 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