Geriatric Care Manager (RN, LPN, or LSW Preferred)

Bluestone Physician Services•Edina, MN

2d•Onsite

About The Position

Bluestone is seeking a field-based Geriatric Clinical Care Manager to support patients with complex chronic illnesses and behavioral health conditions in senior living communities. The role focuses on individualized patient management and serves as a primary link among patients, families, and primary care providers to help ensure a unified care plan is carried out. The Care Manager works to improve patient outcomes, close gaps in care, and reduce unnecessary hospitalizations. The position is 90% field-based direct patient care, primarily in the Edina and Richfield areas. It is full-time, with day-shift hours from 8 a.m. to 5 p.m. Monday through Thursday and 8 a.m. to 3 p.m. Friday, with no evenings, weekends, or holidays. The salary range is $68,500–$80,000, commensurate with experience.

Requirements

Licensed personnel preferred: LPN, RN, or Social Worker.
Strong preference for 3–5 years of direct clinical experience in geriatric care, acute care, post-acute care, or health system discharge planning.
Knowledge of 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 members of the care team.
Effective and professional verbal and written communication skills with diverse populations.
Advanced computer proficiency with email, fax, word processing, spreadsheets, and databases.
Demonstrated compatibility with Bluestone’s mission and operating philosophies.
Ability to read, write, speak, and understand English.

Nice To Haves

Bachelor’s degree or higher.
Experience in behavioral health.
Strong technical skills and experience with electronic health records (EHRs).

Responsibilities

Develop and manage individualized, comprehensive care plans that align with organizational standards and program requirements.
Support patients and families with advance care planning discussions and goal setting.
Carry out the Collaborative Care Model (CoCM) and implement behavioral health interventions.
Collaborate with physicians, certified nurse practitioners, and physician assistants, sharing real-time observations and updating care strategies as patient needs change.
Identify and close clinical and documentation gaps in support of value-based care contracts and ACO initiatives.
Take accountability for quality measures and performance benchmarks, and prevent unnecessary utilization to manage total cost of care.
Coordinate hospital and rehabilitation discharges to support seamless transitions and prevent 30-day readmissions.
Coordinate on-site acute visits, including facilitating telehealth services for timely clinical interventions.
Identify and deploy community and organizational resources to help patients remain in their homes.
Ensure patients are aligned with the most appropriate Bluestone care management program.
Educate families and facility staff about dementia, mental health concerns, and the Bluestone care model.
Serve as a care management contact and streamline communication to support a consistent patient and community experience.
Ensure care management activities meet regulatory requirements.
Maintain a visible presence in assigned communities; the role is 90% field-based.