Care Coordinator, LSW (MSHO)

Bluestone 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. Using an evidence-based approach focused on quality care management and data-driven medical decisions, Bluestone care teams collaborate to manage patients' chronic conditions, address social determinants of health, manage transitions to and from inpatient settings, provide behavioral health support and more. Under our model of care, Bluestone patients experienced 21% fewer ER visits, 36% fewer hospitalizations and 41% fewer hospital readmissions compared to patients with similar conditions and complexities over the same time period. Our care teams travel directly to patients who reside in Assisted Living, Memory Care and Group Home communities throughout Minnesota, Wisconsin and Florida and are supported by clinical operations and administrative colleagues who work remotely or at our corporate offices in Stillwater, Minnesota, and Tampa, Florida. 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 14th year in a row! Bluestone also achieved Top Workplace 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: Join our team as a Care Coordinator, empowering Minnesota's senior population to navigate their healthcare journey and live healthier, more independent lives. In this role, you'll manage Department of Human Services (DHS) and Center for Medicare/Medicaid Services (CMS) requirements for MSHO/MSC+ members. This is a hybrid position where you'll work from home while traveling locally to meet directly with members in their homes and assisted living facilities, helping them access vital medical care, waiver services, and community resources. Schedule: Full-time, 8:00 AM – 5:00 PM (Monday through Thursday) and 8:00 AM – 3:00 PM (Friday). No evenings, weekends, holidays, or on-call requirements. Location: Hybrid — Apple Valley area (50–70% local community visits; 30–50% remote work from home) Salary Range: $65,000 - $75,000, commensurate with experience. Responsibilities: As a Care Coordinator, you will manage member caseloads within your assigned geographic area. Key responsibilities include: Coordinating face-to-face visitsManaging the Elderly WaiverConducting annual assessments including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in Assisted LivingsReviewing current health needs, identifying goals, and developing individualized care plansHelping connect members with community and state resources and servicesHelp members remain safely in their homes and communitiesCompleting required documentationCollaborating with medical care teams to ensure health care quality measures are met and use utilization management tools to meet value-based goalsSupporting members during transitions of care as well as collaborating with their care team to ensure a safe discharge and follow up plan Additional Benefits of Joining Bluestone's Care Coordination Team Comprehensive 6-month onboarding programDedicated preceptor supportOngoing mentoring and coachingContinuing education and professional developmentCollaborative managers who work alongside youExperienced documentation auditors focused on education and quality Qualifications: Education/Certification/Experience Current MN Licensed Social Worker (LSW, LMSW, LISW, or LICSW) - New grads encouraged to apply!OR Minnesota Registered Nurse licenseOne or more years of experience working with the geriatric or certified disabled population in case management/care coordination, Home Care, Group Homes, Nursing Homes, TCU or Assisted Living settings preferredMust have a valid driver's license Knowledge/Skills/Abilities Ability to work independentlyAccess to a private and compliant home office spaceCreative problem-solving skillsAppreciation for working with diverse populationsProven ability to communicate effectively with strong verbal skillsExcellent interpersonal and customer service skillsDemonstrated compatibility with Bluestone's mission and operating philosophiesDemonstrated ability to read, write, speak, and understand the English language Bluestone Benefits: Health InsuranceDental InsuranceVision Materials InsuranceCompany paid Life InsuranceCompany paid Short and Long-term DisabilityHealth Savings Account (with employer contribution)Flexible Spending Account (FSA) Retirement plan with 4% matching contributionsNine (9) paid holidays for office closures plus one (1) floating holidayThree weeks (15 Days) Paid Time Off (PTO)Mileage reimbursement program for field employees Company sponsored cell phone, laptop and scrubsRegular business hours Pay Transparency $65,000—$75,000 USD