Geriatric Complex 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

Disability insurance

401(k) matching

9 paid holidays & 1 floating holiday

Paid PTO (15 days)

Mileage reimbursement

Job summary

Bluestone Physician Services seeks a Geriatric Complex Care Manager to support chronically ill patients in senior living communities across Minnesota. This field-based role connects patients, families, and primary care providers to execute a unified care plan and reduce hospitalizations.

Expect 8-hr days with no evenings or weekends, focusing on care coordination, behavioral health, and transitions. Bluestone offers comprehensive benefits and a strong mission in patient-centered care.

Qualifications

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

Responsibilities

Care Plan Development: Develop and manage individualized, comprehensive care plans that align with program requirements and support patient and family planning.
Behavioral Health Management: Execute on CoCM model and implement specific behavioral health interventions.
Clinical Partnership: Collaborate with MDs, CNPs, and PAs for real-time observations and updated care strategies.
Gaps-in-Care & Utilization Management: Close clinical/documentation gaps to support VBC contracts and TCOC goals.
Transition Management: Lead hospital and rehab discharge coordination to prevent 30-day readmissions.
Acute Care Facilitation: Coordinate on-site acute visits and telehealth to ensure timely interventions.
Resource Optimization: Align community resources to help patients stay in their home and access Bluestone programs.
Education/Relationship Management: Guide families and facility staff on dementia, mental health, and care model basics.

Skills

Value-based care

Care coordination

Discharge planning

Behavioral health

Patient education

EHR proficiency

Education

Bachelor’s degree or higher

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.

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 Complex Care 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 : 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

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