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Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Geriatric Care Manager to join their field-based care team in the Apple Valley, Lakeville, and Burnsville areas of Minnesota. This is a full-time, day-shift position (8am–5pm Monday–Thursday, 8am–3pm Friday) with no evenings, weekends, or holidays.
The role is 90% field-based and focuses on direct patient care and 1:1 relationship management. You will serve as the primary link between patients, families, and primary care providers, ensuring unified care plans are executed for complex, chronically ill patients in assisted living, memory care, and group home communities.
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 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 (VBC) 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 dementia, 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.
Bluestone delivers outcomes by bringing exceptional care to patients with complex, chronic conditions and disabilities. Their multidisciplinary care teams collaborate to deliver preventative, proactive, and tailored care. Bluestone patients experienced 21% fewer ER visits, 36% fewer hospitalizations, and 41% fewer hospital readmissions compared to similar patients. The company has been named to the Star Tribune's Top Workplace list for 14 consecutive years and achieved Top Workplace USA 2021–2026.
**Requirements:**
- Bachelor's degree or higher preferred
- Licensed personnel preferred: RN, LPN, or Licensed 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
- 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 EHR experience preferred
- Demonstrated compatibility with Bluestone's mission and operating philosophies
- Ability to read, write, speak, and understand English
