Field-Based Geriatric Care Manager

Bluestone; Edina (MN); Híbrido; USD 69.000 - 80.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

HSA

FSA

Retirement plan with 4% matching

PTO

Holidays

Mileage reimbursement

Company phone

Company laptop

Regular business hours

Descripción de la vacante

Bluestone seeks a Geriatric Clinical Care Manager to support complex, chronically ill patients in senior living communities across Minnesota. You will link patients, families, and the Primary Care Provider to execute a unified care plan and reduce unnecessary hospitalizations.

This full-time, day-shift role is 90% field-based, collaborating with MDs, CNPs, and PAs to optimize outcomes and transitions across care settings.

Formación

• Bachelor's degree or higher preferred; licensed personnel preferred (LPN, RN, or Social Worker)
• 3–5 years direct clinical experience in geriatric care, acute care, post-acute care, or health system discharge planning
• Experience in behavioral health preferred

Responsabilidades

• Develop and manage individualized care plans that align with standards and program requirements.
• Support patients and families with advance care planning discussions and goal setting.
• Execute behavioral health interventions within the CoCM model.
• Collaborate with MDs, CNPs, and PAs to update care strategies based on patient status.
• Identify and close clinical and documentation gaps to support Value-Based Care contracts.
• Lead the coordination of hospital and rehab discharges to prevent 30-day readmissions.
• Coordinate on-site acute visit coordination, including telehealth services.
• Navigate community resources to keep patients in their home and aligned with Bluestone programs.
• Educate families and facility staff about dementia, mental health, and Bluestone care model.
• Maintain field-based presence (90%) within assigned communities and ensure care model adherence.

Conocimientos

Time management

Organizational skills

Independent worker

Professional communication

Educación

Bachelor's degree or higher

LPN, RN, or Social Worker license preferred

Herramientas

EHR proficiency

MS Office

Descripción del empleo

Bluestone seeks a Geriatric Clinical Care Manager to support complex, chronically ill patients in senior living communities across Minnesota. You will link patients, families, and the Primary Care Provider to execute a unified care plan and reduce unnecessary hospitalizations.

This full-time, day-shift role is 90% field-based, collaborating with MDs, CNPs, and PAs to optimize outcomes and transitions across care settings.