SlipstreamJobs tracks this role from the company's public career site. Apply directly on the employer's site.
Salary: USD 68,500 - 80,000 / annual
Bluestone Physician Services is seeking a Geriatric Complex Care Manager to join their multidisciplinary care teams serving patients with complex, chronic conditions and disabilities in senior living communities across Minnesota, Wisconsin, and Florida.
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 for outcomes. The position is 90% field-based, primarily serving the Buffalo, Monticello, and Elk River areas of Minnesota.
Key Responsibilities:
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 resources to support patients remaining 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 care management communication.
Care Model Integrity: Ensure all activities satisfy regulatory requirements and maintain high-visibility presence in assigned communities.
Schedule: Full-time, day shift. Monday–Thursday 8am–5pm, Friday 8am–3pm. No evenings, weekends, or holidays.
Bluestone's care model has demonstrated significant impact: patients experienced 21% fewer ER visits, 36% fewer hospitalizations, and 41% fewer hospital readmissions compared to similar populations. The company has been named to the Star Tribune's Top Workplace list for 14 consecutive years and achieved Top Workplace USA recognition 2021–2026.
Qualifications:
Education & Certification: Bachelor's degree or higher preferred. Licensed personnel preferred (LPN, RN, or Social Worker).
Experience: 3–5 years 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.
Skills & Abilities: 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 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.
