Geriatric Complex Care Manager

Socket.dev

Apple Valley (MN)

On-site

USD 69,000 - 80,000

Full time

11 days ago

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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 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.

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!

Position Overview

Focused on the 1:1 relationship and patient management. The Geriatric Complex 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 Apple Valley, Lakeville, Burnsville 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.
3-5 years of experience in value-based care, population health, case management and/or 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