Geriatric Care Manager (RN)

Bluestone Physician Services•Buffalo, MN

2d•Onsite

About The Position

Bluestone is hiring a Geriatric Care Manager to provide field-based care management for complex and chronically ill patients and patients with behavioral health conditions in senior living communities. The role focuses on one-to-one patient relationships and serves as the primary link among patients, families, and Primary Care Providers, ensuring a unified care plan is carried out. The Care Manager works to improve patient outcomes, close gaps in care, and reduce unnecessary hospitalizations. This is a full-time, day-shift position. The schedule is 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 position is 90% field-based, primarily in the Buffalo, Monticello, and Elk River areas. 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 care team members.
Ability to communicate effectively and professionally, verbally and in writing, 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 preferred.
Experience in behavioral health preferred.
Strong technical skills and experience with electronic health records (EHRs) preferred.

Responsibilities

Develop and manage individualized, comprehensive care plans in accordance 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, CNPs, and PAs, 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.
Meet quality measures, optimize 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 matched 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 comply with regulatory requirements.
Maintain a high-visibility presence in assigned communities, with approximately 90% of work field-based.