Care Coordinator, RN (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.
About the role
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 — Rogers, Minnesota area (50–70% local community visits; 30–50% remote work from home)
Pay
$65,000 - $75,000, commensurate with experience
Responsibilities
- Manage member caseloads within your assigned geographic area
- Coordinate face-to-face visits
- Manage the Elderly Waiver
- Conduct annual assessments including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in Assisted Livings
- Review current health needs, identify goals, and develop individualized care plans
- Help connect members with community and state resources and services
- Help members remain safely in their homes and communities
- Complete required documentation
- Collaborate with medical care teams to ensure health care quality measures are met and use utilization management tools to meet value-based goals
- Support members during transitions of care as well as collaborate 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 program
- Dedicated preceptor support
- Ongoing mentoring and coaching
- Continuing education and professional development
- Collaborative managers who work alongside you
- Experienced documentation auditors focused on education and quality
Qualifications
- Minnesota Registered Nurse license OR current MN Licensed Social Worker (LSW, LMSW, LISW, or LICSW) - New grads encouraged to apply!
- One 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 preferred
- Must have a valid driver's license
Skills
- Ability to work independently
- Access to a private and compliant home office space
- Creative problem-solving skills
- Appreciation for working with diverse populations
- Proven ability to communicate effectively with strong verbal skills
- Excellent interpersonal and customer service skills
- Demonstrated compatibility with Bluestone's mission and operating philosophies
- Demonstrated ability to read, write, speak, and understand the English language
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 one (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