Geriatric Care Manager

Bluestone Physician Services•Forest Lake, MN

3d•Onsite

About The Position

The Geriatric Care Manager is a specialized, field-based care team member supporting complex and chronically ill patients and behavioral health conditions within senior living communities. The role focuses on one-to-one patient relationships and management, serving as the primary link among the patient, family, and Primary Care Provider 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. This is a full-time, day-shift position with regular hours of 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 role is 90% field-based direct patient care, primarily in the Forest Lake and Hugo areas. Salary is $68,500–$80,000, commensurate with experience.

Requirements

A bachelor's degree or higher is preferred.
Licensed personnel are preferred, including LPNs, RNs, or Social Workers.
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, 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

Experience in behavioral health.
Strong technical skills and experience with 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 status changes.
Identify and close clinical and documentation gaps to support value-based care contracts and ACO initiatives.
Meet quality measures, optimize performance benchmarks, and prevent unnecessary utilization to manage total cost of care.
Coordinate hospital and rehabilitation discharges and support seamless transitions to 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 support patients remaining in their homes.
Help 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 satisfy regulatory requirements.
Maintain a high-visibility presence in assigned communities; the role is 90% field-based.