Care Coordinator, LSW (MSHO)

Bluestone Physician Services•Minneapolis, MN

2d•$65,000 - $75,000•Hybrid

About The Position

Bluestone is hiring a Care Coordinator to help Minnesota’s senior population navigate healthcare and live healthier, more independent lives. The role manages Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) requirements for MSHO/MSC+ members. Care Coordinators manage caseloads within an assigned geographic area and work with members, families, community resources, and medical care teams. This is a hybrid position based in the Minneapolis, Hennepin County area. Work is performed from home and through local travel to meet members in their homes and assisted living facilities. The stated work distribution is 50–70% local community visits and 30–50% remote work from home. The full-time schedule is 8:00 AM–5:00 PM Monday through Thursday and 8:00 AM–3:00 PM Friday. There are no evening, weekend, holiday, or on-call requirements. The salary range is $65,000–$75,000, commensurate with experience. A $2,500 sign-on bonus is paid in two installments: $1,000 after the first 90 days and $1,500 upon reaching the one-year anniversary. Bluestone describes its care model as multidisciplinary, preventative, proactive, and tailored to patients’ needs. Care teams support people with complex, chronic conditions and disabilities, including by managing chronic conditions, addressing social determinants of health, supporting care transitions, and providing behavioral health support. The organization serves patients in assisted living, memory care, and group home communities.

Requirements

Minnesota Registered Nurse license, or current Minnesota Licensed Social Worker credential (LSW, LMSW, LISW, or LICSW).
Valid driver’s license.
Ability to work independently.
Access to a private, compliant home office space.
Creative problem-solving skills.
Appreciation for working with diverse populations.
Effective communication skills, including strong verbal skills.
Excellent interpersonal and customer service skills.
Demonstrated compatibility with Bluestone’s mission and operating philosophies.
Ability to read, write, speak, and understand English.

Nice To Haves

One or more years of experience working with geriatric or certified disabled populations in case management or care coordination, Home Care, Group Homes, Nursing Homes, TCU, or Assisted Living settings.

Responsibilities

Manage member caseloads within an assigned geographic area.
Coordinate face-to-face visits with members.
Manage the Elderly Waiver.
Conduct annual assessments, including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in assisted living facilities.
Review members’ current health needs, identify goals, and develop individualized care plans.
Connect members with community and state resources and services.
Help members remain safely in their homes and communities.
Complete required documentation.
Collaborate with medical care teams to ensure healthcare quality measures are met and use utilization management tools to meet value-based goals.
Support members during care transitions and collaborate with their care teams to ensure a safe discharge and follow-up plan.