Position Overview:

Focused on the 1:1 relationship and patient management. The Geriatric Complex Care Manager is a specialized, field-based care team member responsible for supporting the management of complex and chronically ill patients and behavioral health conditions within senior living communities. Serving as the primary link between the patient, the family, and the Primary Care Provider, this role ensures a single, unified care plan is executed. The Care Manager is accountable for optimizing patient outcomes, closing gaps in care, and reducing unnecessary hospitalizations for a complex, chronically ill population.

Schedule: Full time position, day shift hours, no evenings, weekends or holidays. Hours are 8am to 5pm Monday thru Thursday & 8am to 3pm on Fridays. Location: This position is 90% field-based direct patient care, primarily throughout the Edina and Richfield areas. Salary Range: $68,500 - $80,000. Salary commensurate with experience.

Responsibilities:

Care Coordination

• Care Plan Development: Develop and manage individualized, comprehensive care plans that align with organizational standards and program requirements. Support patients and families with honest advance care planning discussions and goal setting.
• Behavioral Health Management: Execute on CoCM model and implement specific behavioral health interventions.
• Clinical Partnership: Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.
• Gaps-in-Care & Utilization Management: Proactively identify and close clinical and documentation gaps to support Value-Based Care (VBC) contracts, including ACO initiatives. Take accountability for meeting quality measures, optimizing performance benchmarks, and preventing unnecessary utilization to effectively manage the Total Cost of Care (TCOC).

Operational Excellence & Coordination

• Transition Management: Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions.
• Acute Care Facilitation: Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions.
• Resource Optimization: Navigate and deploy community and organizational resources to support the patient’s ability to remain in their home. Ensure patients are aligned with the most optimal Bluestone care management program available.

Community, Patient & Family Support

• Education: Provide expert guidance to families and facility staff regarding dementia, mental health concerns, and the Bluestone care model.
• Relationship Management: Serve as a point of care management contact, ensuring communication is streamlined and the patient and community experience is consistent.

Care Model Integrity

• Care Model Adherence: Ensure all care management activities satisfy regulatory requirements.
• Field-Based Efficiency: Maintain high-visibility presence within assigned communities (90% field-based)

Qualifications:

Education/Certification/Experience

• 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/Skills/Abilities

• 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 members of the care team
• Ability to communicate effectively and professionally, both verbally and in writing, with diverse populations
• Advanced-level of computer proficiency with email, fax, word processing, spreadsheets, and databases
• Strong technical skills and experience with EHRs preferred
• Demonstrated compatibility with Bluestone’s mission and operating philosophies
• Demonstrated ability to read, write, speak, and understand the English language

Bluestone Benefits:

• Health Insurance
• Dental Insurance
• Vision Materials Insurance
• Company paid Life Insurance
• Company paid Short and Long-term Disability
• Health Savings Account (with employer contribution)
• Flexible Spending Account (FSA)
• Retirement plan with 4% matching contributions
• Nine (9) paid holidays for office closures plus on (1) floating holiday
• Three weeks (15 Days) Paid Time Off (PTO)
• Mileage reimbursement program for field employees
• Company sponsored cell phone, laptop and scrubs
• Regular business hours