Geriatric Care Manager (RN)

Bluestone Physician Services•Buffalo, MN

2d•$68,500 - $80,000•Onsite

About The Position

Bluestone is seeking a field-based Geriatric Care Manager to support patients with complex, chronic conditions and behavioral health needs who live in senior living communities. The role focuses on individualized patient management and serves as the primary connection between patients, families, and primary care providers to ensure a unified care plan is carried out. The Care Manager works to improve outcomes, close gaps in care, and reduce avoidable hospitalizations. The position is approximately 90% field-based direct patient care, primarily in the Buffalo, Monticello, and Elk River areas. The Care Manager develops comprehensive care plans, supports advance care planning, implements behavioral health interventions, coordinates with clinicians, and manages transitions from hospitals and rehabilitation settings. The role also coordinates acute visits and telehealth services, connects patients with appropriate resources, supports families and facility staff, and ensures care management activities meet regulatory requirements. 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 evening, weekend, or holiday hours. The salary range is $68,500–$80,000, commensurate with experience.

Requirements

Licensed personnel preferred; examples include LPN, RN, or Social Worker.
Ability to work independently with excellent 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

Bachelor’s degree or higher.
Three to five years of direct clinical experience in geriatric care, acute care, post-acute care, or health system discharge planning.
Experience in behavioral health.
Knowledge of 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 in line with organizational standards and program requirements.
Support patients and families with advance care planning discussions and goal setting.
Execute 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 evolve.
Identify and close clinical and documentation gaps in support of value-based care contracts and ACO initiatives.
Meet quality measures and performance benchmarks while helping prevent unnecessary utilization and 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 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 maintain streamlined communication and a consistent patient and community experience.
Ensure care management activities meet regulatory requirements.
Maintain a visible presence in assigned communities, with approximately 90% of work field-based.