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Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Geriatric Care Manager to join their multidisciplinary care team. This is a field-based role focused on managing complex, chronically ill patients and behavioral health conditions within senior living communities (Assisted Living, Memory Care, and Group Home settings).
You will serve as the primary link between patients, families, and Primary Care Providers, developing and executing individualized care plans that optimize patient outcomes and reduce unnecessary hospitalizations. The role emphasizes a 1:1 relationship model with accountability for closing gaps in care and supporting Value-Based Care (VBC) contracts.
Key responsibilities include:
**Care Coordination:** Develop comprehensive, individualized care plans aligned with organizational standards. Execute behavioral health interventions using the CoCM model. Collaborate directly with MDs, CNPs, and PAs to provide real-time clinical observations and adjust care strategies. Proactively identify and close clinical and documentation gaps to support ACO initiatives and manage Total Cost of Care (TCOC).
**Operational Excellence:** Lead hospital and rehab discharge coordination to prevent 30-day readmissions. Manage on-site acute visit coordination and telehealth facilitation. Navigate community and organizational resources to support patients' ability to remain in their home.
**Community & Family Support:** Provide expert guidance to families and facility staff on dementia, mental health, and the Bluestone care model. Serve as the primary care management contact, ensuring streamlined communication and consistent patient/community experience.
**Care Model Integrity:** Ensure all activities meet regulatory requirements and maintain high-visibility presence within assigned communities (90% field-based).
The position is full-time, day shift (8am–5pm Mon–Thu, 8am–3pm Fri), with no evenings, weekends, or holidays. Work is primarily in the Forest Lake and Hugo areas of Minnesota.
**Requirements:**
- Bachelor's degree or higher preferred; Licensed personnel preferred (LPN, RN, or Social Worker)
- Strong preference for 3–5 years of direct clinical experience in geriatric care, acute care, post-acute care, or health system discharge planning
- Experience in behavioral health preferred
- 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 with care team members
- Effective verbal and written communication skills with diverse populations
- Advanced computer proficiency (email, word processing, spreadsheets, databases); EHR experience preferred
- Fluency in English (read, write, speak, understand)
- Demonstrated compatibility with Bluestone's mission and operating philosophies
