Geriatric Complex Care Manager

Bluestone Physician Services; Edina (MN); On-site; USD 69,000 - 80,000; Full time

Benefits offered by this job

Health Insurance

Company paid Short and Long-term_Dis_

Health Savings Account (with employer

Flexible Spending Account (FSA)

Retirement plan with 4% matching_contr

Nine (9) paid holidays for office clos

Mileage reimbursement program for fiel

Company sponsored cell phone, laptop

Regular business hours

Job summary

Bluestone Physician Services in Edina, MN seeks a Geriatric Complex Care Manager to support the management of complex, chronically ill patients in senior living communities. You will act as the primary link among patients, families and primary care providers to ensure a unified care plan and to optimize outcomes.

This full-time, day-shift role is 90% field-based across Minnesota, with hospital discharge coordination, care transitions, and collaboration with MDs, CNPs and PAs.

Qualifications

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

Responsibilities

• Develop and manage individualized care plans and support families with advance care planning discussions and goal setting.
• Execute on CoCM model and implement specific behavioral health interventions.
• Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.
• Proactively identify and close clinical and documentation gaps to support Value-Based Care contracts and prevent unnecessary utilization to manage Total Cost of Care.
• Lead the coordination of hospital and rehab discharges to ensure seamless transitions and prevent 30-day readmissions.
• Manage on-site acute visit coordination and telehealth services for timely clinical interventions.
• Navigate community resources to support the patient’s ability to remain in their home and align with Bluestone programs.
• Educate families and facility staff on dementia, mental health, and Bluestone care model.
• Maintain a 90% field-based presence within assigned communities.

Skills

Value-based care

Population health

Care coordination

Discharge planning

Behavioral health

Time management

Education

Bachelor's degree or higher preferred; Licensed personnel preferred - LPN, RN, or Social Worker

Tools

EHRs

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, primarily throughout the Edina and Richfield 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 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, care coordination 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

• Health Insurance
• Company paid Short and Long-term Disability
• Health Savings Account (with employer contribution)
• Flexible Spending Account (FSA)
• Retirement plan with 4% matching contributions
• Nine (9) paid holidays for office closures plus on (1) floating holiday
• Mileage reimbursement program for field employees
• Company sponsored cell phone, laptop and scrubs
• Regular business hours

Pay Transparency

$68,500 - $80,000 USD

As set forth in Bluestone Physician Services’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.