Care Coordinator, LSW

Job Description

Job Description

Bluestone Physician Services delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Our unique, robust model of care goes beyond primary care services — our multidisciplinary care teams collaborate with patients, their families and other healthcare providers to deliver care that is preventative, proactive and tailored to their unique needs. Our care teams travel to patients who reside in Assisted Living, Memory Care and Group Home communities throughout Minnesota, Wisconsin and Florida.

In addition to primary care, Bluestone has a highly developed care coordination model for more than 14,000 seniors and individuals living with disabilities in Minnesota. Bluestone Care Coordination partners with Minnesota health plans to support their members who receive medical assistance through Minnesota’s Special Needs BasicCare (SNBC) & Minnesota Senior Health Options (MSHO) programs. Care Coordinators are registered nurses or licensed social workers who work directly with members to assess their physical, mental and social needs and facilitate services and communication across their care team to support their best interests and close gaps in care.

Our success is only possible through the hard work of our employees who bring our core values of Dedication, Excellence, Collaboration and Caring to life every day. Bluestone has been named to the Star Tribune's Top Workplace list for the 13th year in a row! Bluestone also achieved Top Workplace USA 2021-2025!

Position Overview :

Join our team as a Care Coordinator where you will work with the senior population managing Department of Human Services (DHS) and Center for Medicare / Medicaid Services (CMS) required activities for Minnesota Senior Health Options (MSHO / MSC+) members living in the community and assisted living facilities. In this position, you will work from home, but regularly travel your local area to serve the needs of your members and your community.

Schedule : Full time position, day shift hours, no evenings, weekends or holidays. Hours are 8am to 5pm Monday thru Thursday & 8am to 3pm on Fridays.

Location :  ~50-70% travel throughout Virginia, Cook, Ely, and Embarrass, MN areas, ~30-50% remote work from home.

Salary Range : $65,000 - $75,000

Responsibilities :

As a Care Coordinator, you will manage member caseloads within your assigned geographic area. This includes :

• Coordinating face-to-face visits
• Managing the Elderly Waiver
• Conducting annual assessments including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in Assisted Livings
• Reviewing current health needs, identifying goals, and developing individualized care plans
• Helping connect members with community and state resources and services
• Completing required documentation
• Collaborating with medical care teams to ensure health care quality measures are met and use utilization management tools to meet value-based goals
• Supporting members during transitions of care as well as collaborating with their care team to ensure a safe discharge and follow up plan

Qualifications :

Education / Certification / Experience

Knowledge / Skills / Abilities

Bluestone Benefits :

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