Geriatric Care Manager

Bluestone Physician Services

Minnesota

On-site

USD 69,000 - 80,000

Full time

14 days+

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Benefits offered by this job

Health Insurance

Dental Insurance

Vision Materials Insurance

Company paid Life Insurance

Company paid Short and Long-term Disab

Health Savings Account

Flexible Spending Account

Retirement plan with 4% matching

Nine (9) paid holidays

Three weeks (15 Days) PTO

Mileage reimbursement

Cell phone, laptop and scrubs

Regular business hours

Job summary

Bluestone Physician Services in Minnesota is seeking a Geriatric Clinical Care Manager to support complex, chronically ill patients and behavioral health conditions in senior living communities. You will be the primary link between patient, family and Primary Care Provider to ensure a single, unified care plan.

The role is full-time with 90% field-based scope, mainly in Buffalo, Monticello and Elk River, working with MDs, NPs and other care teams to reduce hospitalizations and optimize outcomes.

Qualifications

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

Responsibilities

Care Coordination: Develop and manage individualized, comprehensive care plans and support families with advance care planning.
Behavioral Health Management: Implement CoCM-based interventions.
Clinical Partnership: Collaborate with MDs, CNPs, and PAs for real-time updates.
Gaps-in-Care & Utilization Management: Close gaps to support VBC contracts and quality measures.
Transition Management: Lead hospital and rehab discharge coordination to prevent readmissions.
Acute Care Facilitation: Coordinate on-site visits and telehealth for timely interventions.
Resource Optimization: Deploy community resources to help patients stay at home.
Education: Guide families and facility staff on dementia and Bluestone care model.
Relationship Management: Maintain clear communication with care teams and patients.
Care Model Integrity: Ensure activities meet regulatory requirements.

Skills

Geriatric care

Care coordination

Behavioral health

Independent work

EHR proficiency

Education

Bachelor's degree or higher preferred

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

3–5 years direct clinical experience

Tools

EHR systems

Job description

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

Focused on the 1:1 relationship and patient management. The Geriatric Clinical Care Manager is a specialized, field-based care team member responsible for supporting the management of complex and chronically ill patients and behavioral health conditions within senior living communities. Serving as the primary link between the patient, the family, and the Primary Care Provider, this role ensures a single, unified care plan is executed. The Care Manager is accountable for optimizing patient outcomes, closing gaps in care, and reducing unnecessary hospitalizations for a complex, chronically ill population.

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 Buffalo, Monticello, Elk River 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 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 Integrity

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.
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.

Knowledge/Skills/Abilities

Knowledge and experience with Assisted Living and Memory Care communities
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: