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Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Geriatric Complex Care Manager to deliver specialized care coordination for complex, chronically ill patients and behavioral health conditions within senior living communities. This is a field-based role focused on 1:1 patient relationships and care management.
You will serve as the primary link between patients, families, and Primary Care Providers, ensuring unified care plans are executed and optimized. Key responsibilities include developing and managing individualized, comprehensive 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 proactively identifying and closing clinical and documentation gaps to support Value-Based Care (VBC) contracts and ACO initiatives.
Operationally, you will lead coordination of hospital and rehab discharges to prevent 30-day readmissions, manage on-site acute visit coordination including telehealth facilitation, and navigate community and organizational resources to support patients' ability to remain in their homes. You will also provide expert guidance to families and facility staff regarding dementia, mental health concerns, and the Bluestone care model, while serving as a consistent point of contact for care management communication.
The role is 90% field-based, primarily throughout the Edina and Richfield areas, with regular business hours: Monday–Thursday 8am–5pm, Friday 8am–3pm. No evenings, weekends, or holidays. Bluestone'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)
- 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 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
- Strong 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
