Geriatric Care Manager

Bluestone Physician Services•Forest Lake, MN

3d•$68,500 - $80,000•Onsite

About The Position

The Geriatric Care Manager is a specialized, field-based care team member who supports the management of complex and chronically ill patients and behavioral health conditions in senior living communities. The role focuses on one-to-one patient relationships and management, and serves as the primary link between patients, families, and Primary Care Providers to ensure a unified care plan is carried out. The Care Manager is accountable for optimizing patient outcomes, closing gaps in care, and reducing unnecessary hospitalizations. This is a full-time, day-shift role with regular hours of 8:00 a.m. to 5:00 p.m. Monday through Thursday and 8:00 a.m. to 3:00 p.m. Friday, with no evenings, weekends, or holidays. The position is 90% field-based direct patient care, mainly in the Forest Lake and Hugo areas. The stated salary range is $68,500–$80,000, commensurate with experience. Bluestone provides care to patients with complex, chronic conditions and disabilities through multidisciplinary teams that collaborate with patients, families, and other healthcare providers. Its care model includes chronic condition management, attention to social determinants of health, transitions to and from inpatient settings, and behavioral health support. Care teams visit patients in Assisted Living, Memory Care, and Group Home communities. Clinical operations and administrative colleagues support the teams remotely or from corporate offices in Stillwater, Minnesota, and Tampa, Florida.

Requirements

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 strong 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 preferred.
Licensed personnel preferred, including LPN, RN, or Social Worker.
Behavioral health experience preferred.
Strong technical skills and experience with EHRs preferred.

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 MDs, CNPs, and PAs, 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 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, and align patients 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 high-visibility presence in assigned communities, with 90% of work field-based.