Field-Based Geriatric Care Navigator

Socket.dev; Apple Valley (MN); On-site; USD 69,000 - 80,000; Full time

Benefits offered by this job

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Matching

Paid Holidays

PTO

Job summary

Bluestone is seeking a Geriatric Complex Care Manager to support frail, chronically ill patients in senior living communities across Minnesota. This field-based role links patients, families, and the Primary Care Provider to ensure a single, unified care plan and improved outcomes.

Responsibilities include care coordination, transitions management, behavioral health support, and collaboration with MDs, CNPs, and PAs to prevent unnecessary hospitalizations and optimize total cost of care.

Qualifications

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

Responsibilities

• Care Plan Development and management tailored to each patient.
• Behavioral Health interventions within the CoCM model.
• Collaborate with MDs, CNPs, and PAs for real-time updates.
• Close gaps in care and manage utilization to optimize outcomes.
• Lead hospital and rehab discharge transitions to prevent readmissions.
• Coordinate on-site acute visits and telehealth interventions.
• Deploy community resources to support home-based care.
• Educate families and facility staff on dementia, mental health, and Bluestone model.
• Maintain care-model integrity and regulatory adherence.
• Maintain 90% field-based visibility in communities.

Skills

Assisted Living knowledge

Time management

Organization

Relationship building

Communication

Computer skills

EHR systems

English proficiency

Education

Bachelor's degree or higher

LPN/RN/Social Worker license preferred

Tools

EHR systems

Job description

Bluestone is seeking a Geriatric Complex Care Manager to support frail, chronically ill patients in senior living communities across Minnesota. This field-based role links patients, families, and the Primary Care Provider to ensure a single, unified care plan and improved outcomes.

Responsibilities include care coordination, transitions management, behavioral health support, and collaboration with MDs, CNPs, and PAs to prevent unnecessary hospitalizations and optimize total cost of care.