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Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Geriatric Care Manager to deliver specialized, field-based care coordination for complex and chronically ill patients in senior living communities. This role focuses on 1:1 patient relationships and management, serving as the primary link between patients, families, and primary care providers to ensure unified, evidence-based care plans are executed.
The position is 90% field-based, primarily serving patients in Forest Lake and Hugo, Minnesota, within Assisted Living, Memory Care, and Group Home communities. You will work full-time day shifts (8am–5pm Mon–Thu, 8am–3pm Fri) with no evenings, weekends, or holidays.
Key responsibilities include:
**Care Coordination:** Develop and manage individualized, comprehensive care plans aligned with organizational standards. Support patients and families with advance care planning discussions. Execute behavioral health interventions using the CoCM model. 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, managing Total Cost of Care and quality measures.
**Operational Excellence:** Lead coordination of hospital and rehab discharges to 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 homes.
**Community & Family Support:** Provide expert guidance to families and facility staff on dementia, mental health, and the Bluestone care model. Serve as a consistent point of contact for streamlined communication.
**Care Model Integrity:** Ensure all care management activities satisfy regulatory requirements and maintain high-visibility presence within assigned communities.
Bluestone delivers outcomes through multidisciplinary care teams that address social determinants of health, manage chronic conditions, and provide behavioral health support. The organization has demonstrated significant impact: patients experienced 21% fewer ER visits, 36% fewer hospitalizations, and 41% fewer hospital readmissions compared to similar populations. Bluestone 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
- 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, fax, word processing, spreadsheets, databases)
- Strong technical skills and EHR experience preferred
- Fluency in English (read, write, speak, understand)
- Demonstrated compatibility with Bluestone's mission and operating philosophies
