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

Bluestone Physician Services•Apple Valley, MN

1d•Onsite

About The Position

Bluestone’s Geriatric Care Manager is a specialized, field-based care team member who supports complex and chronically ill patients and behavioral health needs in senior living communities. The role is focused on one-to-one patient relationships and management, serving as the primary link among patients, families, and primary care providers to help ensure a unified care plan is carried out. The Care Manager works to optimize patient outcomes, close gaps in care, and reduce unnecessary hospitalizations. The position is approximately 90% field-based direct patient care, primarily in the Apple Valley, Lakeville, and Burnsville areas. The schedule is full time, during regular day-shift business hours, with no evenings, weekends, or holidays. Hours are 8:00 a.m. to 5:00 p.m. Monday through Thursday and 8:00 a.m. to 3:00 p.m. Friday. Salary is $68,500–$80,000, commensurate with experience. The Care Manager develops and manages individualized care plans, supports advance care planning, implements behavioral health interventions, and collaborates with physicians and advanced practice providers. The role also coordinates care transitions and acute visits, connects patients with community and organizational resources, educates families and facility staff, and ensures care management activities meet regulatory requirements.

Requirements

A bachelor’s degree or higher is preferred.
Licensed personnel are 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.
Ability to work independently with strong time-management and organizational skills.
Ability to maintain professional relationships with members of the care team.
Ability to communicate effectively and professionally, verbally and in writing, with diverse populations.
Advanced computer proficiency, including 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

Experience in behavioral health.
Knowledge and experience with Assisted Living and Memory Care communities.
Strong technical skills and experience with electronic health records (EHRs).

Responsibilities

Develop and manage individualized, comprehensive care plans aligned 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 status changes.
Identify and close clinical and documentation gaps in support of value-based care contracts and ACO initiatives.
Take accountability for quality measures, performance benchmarks, and preventing 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 and facilitate telehealth services for timely clinical interventions.
Identify and deploy community and organizational resources that support patients remaining 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 Bluestone’s care model.
Serve as a care management point of contact and streamline communication to support a consistent patient and community experience.
Ensure care management activities comply with regulatory requirements.
Maintain a high-visibility presence in assigned communities; approximately 90% of the role is field-based.