Care Manager - Disability & Behavioral Support

Bluestone Physician Services; Minnesota; Hybrid; 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 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 behavior