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Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Geriatric Care Manager (LSW preferred) to join their multidisciplinary care team. This is a field-based role focused on delivering exceptional care to patients living with complex, chronic conditions and disabilities in senior living communities.
You will serve as the primary link between patients, families, and primary care providers, developing and managing individualized care plans that optimize patient outcomes and reduce unnecessary hospitalizations. The role emphasizes a 1:1 relationship with patients and accountability for closing gaps in care.
Key responsibilities include:
- Developing comprehensive, individualized care plans aligned with organizational standards
- Executing behavioral health interventions using the CoCM model
- Collaborating directly with MDs, CNPs, and PAs to provide real-time clinical observations and adjust care strategies
- Proactively identifying and closing clinical and documentation gaps to support Value-Based Care contracts and ACO initiatives
- Leading coordination of hospital and rehab discharges to prevent 30-day readmissions
- Managing on-site acute visit coordination and telehealth facilitation
- Navigating community and organizational resources to support patients' ability to remain in their home
- Providing expert guidance to families and facility staff on dementia, mental health, and the Bluestone care model
- Maintaining a high-visibility presence within assigned communities (90% field-based)
The position is 90% field-based, serving patients primarily throughout the Buffalo, Monticello, and Elk River areas. Schedule is full-time day shift: Monday–Thursday 8am–5pm, Friday 8am–3pm. No evenings, weekends, or holidays.
Bluestone has been named to the Star Tribune's Top Workplace list for 14 consecutive years and achieved Top Workplace USA 2021–2026. The organization's care model has demonstrated significant outcomes: patients experienced 21% fewer ER visits, 36% fewer hospitalizations, and 41% fewer hospital readmissions compared to similar populations.
Qualifications:
- Bachelor's degree or higher preferred
- Licensed personnel preferred: LPN, RN, or Social Worker (LSW)
- 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
- Excellent verbal and written communication skills with diverse populations
- Advanced computer proficiency (email, fax, word processing, spreadsheets, databases)
- Strong EHR experience preferred
- Fluency in English (read, write, speak, understand)
- Demonstrated compatibility with Bluestone's mission and operating philosophies
