Geriatric Care Manager - Field-Based 1:1 Patient Care

Bluestone Physician Services; Minnesota; On-site; USD 69,000 - 80,000; Full time

Job summary

Bluestone Physician Services seeks a Geriatric Clinical Care Manager (RN, LPN, LSW) to support patients with complex, chronic conditions in Minnesota communities. This field-based role emphasizes care coordination, behavioral health, and reducing hospitalizations, collaborating with families and primary care providers.

The role collaborates closely with physicians and PAs to optimize patient outcomes. The position is full-time with on-site field work across Buffalo, Monticello, and Elk River

Qualifications

• 1:1 patient management experience.
• Experience with chronic and complex care.
• Ability to coordinate care plans with families.
• Strong collaboration with physicians and PAs.

Responsibilities

• Develop and manage individualized care plans.
• Coordinate transitions and prevent 30-day readmissions.
• Collaborate with MDs, CNPs, and PAs on care updates.
• Deliver behavioral health interventions within the CoCM model.
• Provide education to patients and families.

Skills

Care Coordination

Behavioral Health

Clinical Partnerships

Gaps in Care

Transition Management

Care Plan Development

Education Support

Acute Care Liaison

Job description

Bluestone Physician Services seeks a Geriatric Clinical Care Manager (RN, LPN, LSW) to support patients with complex, chronic conditions in Minnesota communities. This field-based role emphasizes care coordination, behavioral health, and reducing hospitalizations, collaborating with families and primary care providers.

The role collaborates closely with physicians and PAs to optimize patient outcomes. The position is full-time with on-site field work across Buffalo, Monticello, and Elk River