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Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Care Manager to deliver comprehensive support for individuals with disabilities and persistent mental health conditions residing in group homes and assisted living settings across Minnesota. This is a full-time, day-shift position (8am–5pm Mon–Thu, 8am–3pm Fri) with no evenings, weekends, or holidays.
The Care Manager serves as the primary point of contact connecting patients, families, and Primary Care Providers. The role is 90% field-based, primarily in the Maple Grove and Rogers areas, and focuses on individualized care management and relationship building.
Key responsibilities include:
**Care Coordination:** Develop and manage individualized, comprehensive care plans aligned with organizational standards. Support patients and families with advance care planning and goal setting. Execute on Collaborative Care Model (CoCM) and implement behavioral health interventions. Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies. Proactively identify and close clinical and documentation gaps to support Value-Based Care contracts and ACO initiatives, taking accountability for quality measures and preventing unnecessary utilization.
**Operational Excellence:** Lead coordination of hospital and rehab discharges to ensure seamless transitions and prevent 30-day readmissions. Manage on-site acute visit coordination and telehealth facilitation. Navigate and deploy community and organizational resources to support patients' ability to remain in their home.
**Community, Patient & Family Support:** Provide expert guidance to families and facility staff regarding behavioral and mental health concerns and the Bluestone care model. Serve as a consistent point of care management contact.
**Care Model Integrity:** Ensure all care management activities satisfy regulatory requirements and maintain high-visibility presence within assigned communities.
Bluestonedelivers outcomes through evidence-based care management and data-driven medical decisions. Their patients experienced 21% fewer ER visits, 36% fewer hospitalizations, and 41% fewer hospital readmissions compared to similar patient populations. The company has been named to the Star Tribune's Top Workplace list for 14 consecutive years and achieved Top Workplace USA recognition 2021–2026.
**Requirements:**
- 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 and experience working with individuals with disabilities and persistent mental health conditions in residential care environments
- Ability to work independently with excellent time-management and organizational skills
- Ability to maintain professional relationships with members of the care team
- Ability to communicate effectively and professionally, both verbally and in writing, with diverse populations
- Advanced-level 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 English
