Geriatric Complex Care Manager

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 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 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, 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 • Dental Insurance • Vision Materials Insurance • Company paid Life 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 • Three weeks (15 Days) Paid Time Off (PTO) • Mileage reimbursement program for field employees • Company sponsored cell phone, laptop and scrubs • Regular business hours​ ​ Pay Transparency $68,500—$80,000 USD