Care Manager - Disability & Behavioral Support

Bluestone Physician Services

Saint Paul (MN)

On-site

USD 69,000 - 80,000

Full time

7 days ago

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Benefits offered by this job

Health Insurance

Short and Long-term Disability

Health Savings Account (with employer)

Flexible Spending Account (FSA)

Retirement plan with 4% matching

9 paid holidays + 1 floating holiday

Mileage reimbursement

Company cell phone, laptop and scrubs

Regular business hours

Job summary

Bluestone Physician Services in Minnesota is seeking an experienced Care Manager to deliver 1:1, disability-focused care management for individuals in group homes and assisted living settings. You will connect patients, families and primary care providers to implement unified care plans and prevent avoidable hospitalizations.

This full-time, 8am–5pm Monday-Thursday and 8am–3pm Friday role is 90% field-based across the St.

Qualifications

Bachelor’s degree or higher preferred; licensure in nursing or social work preferred.
3–5 years in value-based care, population health, case management, or discharge planning.
Experience with behavioral health preferred.
Disability and residential care experience highly valued.

Responsibilities

Develop and manage individualized care plans aligned with organizational standards.
Collaborate directly with MDs, CNPs, and PAs to update care strategies.
Identify and close care gaps to support value-based contracts.
Lead hospital discharge transitions to prevent 30-day readmissions.
Coordinate telehealth and on-site visits for timely care.
Maintain high-visibility field-based presence in assigned communities.

Skills

Disability care experience

Time management

Team relationships

Communication

Computer proficiency

EHR experience

Mission alignment

English proficiency

Education

Bachelor’s degree or higher preferred

Licensed personnel preferred (LPN, RN, or Social Worker)

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 St. Paul, Inver Grove Heights and Cottage Grove 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: