Geriatric Complex Care Manager

Bluestone Physician Services•Edina, MN

2d•$68,500 - $80,000•Hybrid

About The Position

Focused on the 1:1 relationship and patient management. The Geriatric Complex Care Manager is a specialized, field-based care team member responsible for supporting the management of complex and chronically ill patients and behavioral health conditions within senior living communities. Serving as the primary link between the patient, the family, and the Primary Care Provider, this role ensures a single, unified care plan is executed. The Care Manager is accountable for optimizing patient outcomes, closing gaps in care, and reducing unnecessary hospitalizations for a complex, chronically ill population.

Requirements

Bachelor's degree or higher preferred. Licensed personnel preferred - LPN, RN, or Social Worker.
3-5 years of experience in value-based care, population health, case management, care coordination and/or discharge planning.
Experience in behavioral health preferred.
Knowledge 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 members of the care team
Ability to communicate effectively and professionally, both verbally and in writing, with diverse populations
Advanced-level of computer proficiency with email, fax, word processing, spreadsheets, and databases
Strong technical skills and experience with EHRs preferred
Demonstrated compatibility with Bluestone’s mission and operating philosophies
Demonstrated ability to read, write, speak, and understand the English language

Responsibilities

Develop and manage individualized, comprehensive care plans that align with organizational standards and program requirements. Support patients and families with honest advance care planning discussions and goal setting.
Execute on CoCM model and implement specific behavioral health interventions.
Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.
Proactively identify and close clinical and documentation gaps to support Value-Based Care (VBC) contracts, including ACO initiatives. Take accountability for meeting quality measures, optimizing performance benchmarks, and preventing unnecessary utilization to effectively manage the Total Cost of Care (TCOC).
Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions.
Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions.
Navigate and deploy community and organizational resources to support the patient’s ability to remain in their home. Ensure patients are aligned with the most optimal Bluestone care management program available.
Provide expert guidance to families and facility staff regarding dementia, mental health concerns, and the Bluestone care model.
Serve as a point of care management contact, ensuring communication is streamlined and the patient and community experience is consistent.
Ensure all care management activities satisfy regulatory requirements.
Maintain high-visibility presence within assigned communities (90% field-based)