Field-Based Geriatric Care Manager – Senior Living

Bluestone Physician Services; Edina (MN); On-site; USD 69,000 - 80,000; Full time

Benefits offered by this job

Health Insurance

Company paid Short and Long-term_Dis_

Health Savings Account (with employer

Flexible Spending Account (FSA)

Retirement plan with 4% matching_contr

Nine (9) paid holidays for office clos

Mileage reimbursement program for fiel

Company sponsored cell phone, laptop

Regular business hours

Job summary

Bluestone Physician Services in Edina, MN seeks a Geriatric Complex Care Manager to support the management of complex, chronically ill patients in senior living communities. You will act as the primary link among patients, families and primary care providers to ensure a unified care plan and to optimize outcomes.

This full-time, day-shift role is 90% field-based across Minnesota, with hospital discharge coordination, care transitions, and collaboration with MDs, CNPs and PAs.

Qualifications

• Bachelor's degree or higher preferred; licensed personnel preferred (LPN, RN, or Social Worker).
• 3-5 years in value-based care, population health, case management, care coordination or discharge planning.
• Experience in behavioral health preferred.

Responsibilities

• Develop and manage individualized care plans and support families with advance care planning discussions and goal setting.
• Execute on CoCM model and implement specific behavioral health interventions.
• Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.
• Proactively identify and close clinical and documentation gaps to support Value-Based Care contracts and prevent unnecessary utilization to manage Total Cost of Care.
• Lead the coordination of hospital and rehab discharges to ensure seamless transitions and prevent 30-day readmissions.
• Manage on-site acute visit coordination and telehealth services for timely clinical interventions.
• Navigate community resources to support the patient’s ability to remain in their home and align with Bluestone programs.
• Educate families and facility staff on dementia, mental health, and Bluestone care model.
• Maintain a 90% field-based presence within assigned communities.

Skills

Value-based care

Population health

Care coordination

Discharge planning

Behavioral health

Time management

Education

Bachelor's degree or higher preferred; Licensed personnel preferred - LPN, RN, or Social Worker

Tools

EHRs

Job description

Bluestone Physician Services in Edina, MN seeks a Geriatric Complex Care Manager to support the management of complex, chronically ill patients in senior living communities. You will act as the primary link among patients, families and primary care providers to ensure a unified care plan and to optimize outcomes.

This full-time, day-shift role is 90% field-based across Minnesota, with hospital discharge coordination, care transitions, and collaboration with MDs, CNPs and PAs.