Geriatric Clinical Care Manager - RN, LPN, LSW

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

Geriatric Clinical Care Manager - RN, LPN, LSW

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 ClinicalCare Manager is a specialized, field-based care team member responsible for supporting the management ofcomplex and chronically ill patients and behavioral health conditions within senior living communities. Serving as theprimary link between the patient, the family, and the Primary Care Provider, this role ensures a single, unified care plan isexecuted. The Care Manager is accountable for optimizing patient outcomes, closing gaps in care, and reducingunnecessary 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