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USA 2021-2026!

In 2022, Bluestone Accountable Care Organization (ACO) was the best performing ACO in the country as measured by the overall savings per Medicare beneficiary.

Position Overview :

Centered on individualized care management and 1:1 relationship building, the Care Manager drives comprehensive support for individuals with disabilities and persistent mental health conditions residing in group homes and assisted living settings. As the primary point of contact connecting individuals, families, and Primary Care Providers, the Care Manager ensures the seamless execution of a unified care plan while taking ownership of health outcomes, care gap closure, and the prevention of avoidable hospitalizations.

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 :

This position is 90% field-based direct patient care, mainly throughout the St. Paul, Inver Grove Heights and Cottage Grove areas.

Salary Range :

$68,500 - $80,000. Salary commensurate with experience.

Responsibilities :

Care Coordination Care Plan Development:

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.

Behavioral Health Management:

Execute on CoCM model and implement specific behavioral health interventions.

Clinical Partnership:

Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient's evolving status.

Gaps-in-Care & Utilization Management:

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).

Operational Excellence & Coordination Transition Management:

Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions.

Acute Care Facilitation:

Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions.

Resource Optimization:

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.

Community, Patient & Family Support Education :

Provide expert guidance to families and facility staff regarding behavioral and mental health concerns, and the Bluestone care model.

Relationship Management :

Serve as a point of care management contact, ensuring communication is streamlined and the patient and community experience is consistent.

Care Model Integrity Care Model Adherence :

Ensure all care management activities satisfy regulatory requirements.

Field-Based Efficiency :

Maintain high-visibility presence within assigned communities (90% field-based)

Qualifications :

Education/Certification/Experience 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/Skills/Abilities Proven experience working with individuals with disabilities and persistent mental health conditions in residential care environments 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

Bluestone Benefits:

Health Insurance Dental Insurance Vision Materials Insurance Company paid Life Insurance Company paid Short and Long-term Disability Health Savings Account (with employer contribution) Flexible Spending Account (FSA) Retirement plan with 4% matching contributions Nine (9) paid holidays for office closures plus on (1) floating holiday Three weeks (15 Days) Paid Time Off (PTO) Mileage reimbursement program for field employees Company sponsored cell phone, laptop and scrubs Regular business hours","type","jobPosting","source","LC","accountId","60797639","organizationName","Bluestone Physician Services","applicationUrl","https://www.indeed.com/viewjob?jk=cb1a8c15e812bde9&from=serp&vjs=3","Inver Grove Heights, 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Find & Apply For Nursing Home / Home Health Administrator Jobs in Inver Grove Heights, Minnesota

Care Manager - Disability & Behavioral Support