Field-Based Geriatric Care Manager

Bluestone Physician Services; Forest Lake (MN); Presencial; USD 69.000 - 80.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health Insurance

Dental Insurance

Vision Insurance

Company paid Life Insurance

Disability Insurance

Health Savings Account (HSA)

Flexible Spending Account (FSA)

Retirement plan with 4% matching

Paid holidays and PTO

Mileage reimbursement

Company laptop and scrubs

Regular business hours

Descripción de la vacante

Bluestone Physician Services is seeking a Geriatric Care Manager for Minnesota-based senior living communities. The role focuses on 1:1 patient management, care plan execution, and collaboration with families and primary care providers.

It aims to reduce hospitalizations and optimize outcomes through a unified care plan. The position is 90% field-based, dedicated to Forest Lake and surrounding areas, with a full-time day schedule (8am–5pm Mon–Thu, 8am–3pm Fri).

Formación

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

Responsabilidades

• 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).
• 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.
• Education: Provide expert guidance to families and facility staff regarding dementia, 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)

Conocimientos

Assisted Living

Memory Care

Time management

Professional communication

EHR proficiency

Team collaboration

Educación

Bachelor’s degree or higher

Licensed personnel (LPN/RN/Social Worker)

Descripción del empleo

Bluestone Physician Services is seeking a Geriatric Care Manager for Minnesota-based senior living communities. The role focuses on 1:1 patient management, care plan execution, and collaboration with families and primary care providers.

It aims to reduce hospitalizations and optimize outcomes through a unified care plan. The position is 90% field-based, dedicated to Forest Lake and surrounding areas, with a full-time day schedule (8am–5pm Mon–Thu, 8am–3pm Fri).