Care Manager - Disability & Behavioral Support

Bluestone Physician Services•St. Paul, MN

8d•$68,500 - $80,000•Hybrid

About The Position

Centered on individualized care management and 1:1 relationship building, the Care Manager drives comprehensive support for individuals with disabilities and persistent mental health conditions residing in group homes and assisted living settings. As the primary point of contact connecting individuals, families, and Primary Care Providers, the Care Manager ensures the seamless execution of a unified care plan while taking ownership of health outcomes, care gap closure, and the prevention of avoidable hospitalizations. This position is 90% field-based direct patient care, mainly throughout the St. Paul, Inver Grove Heights and Cottage Grove areas.

Requirements

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.
Proven experience working with individuals with disabilities and persistent mental health conditions in residential care environments
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
Demonstrated compatibility with Bluestone’s mission and operating philosophies
Demonstrated ability to read, write, speak, and understand the English language

Nice To Haves

Experience in behavioral health preferred.
Strong technical skills and experience with EHRs preferred.

Responsibilities

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.
Execute on CoCM model and implement specific behavioral health interventions.
Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.
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).
Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions.
Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions.
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.
Provide expert guidance to families and facility staff regarding behavioral and mental health concerns, and the Bluestone care model.
Serve as a point of care management contact, ensuring communication is streamlined and the patient and community experience is consistent.
Ensure all care management activities satisfy regulatory requirements.
Maintain high-visibility presence within assigned communities (90% field-based).