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.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 13th year in a row! Bluestone also achieved Top Workplace USA 2021-2024! In 2022, Bluestone Accountable Care Organization (ACO) was the as measured by the overall savings per Medicare beneficiary.Position Overview:As a GUIDE Model Dementia Case Manager, you will assist in delivering the 9 core elements outlined in the CMMI GUIDE Model of care delivery. You will build strong, collaborative relationships with internal teams as well as external partners to ensure patients and caregivers receive appropriate and high quality care. Assessment, care planning, coordination of care and resources, and transitional care management are foundational to the position. The Care Navigator position allows for great work-life balance, with approximately 20% remote and 80% of the time allowing you to directly impact patients, team members and community partners.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 entails a mix of remote work, as well as about 80% direct patient care mainly throughout Minneapolis, St. Paul, Eagan areasSalary Range: $65,000 - $80,000, $1,000 Sign-on Bonus, Salary will be commensurate with experienceResponsibilities:

Conducting comprehensive assessments that include clinical, behavioral, psychosocial, and advance care planning domains
Reviewing current health needs, identifying goals, and developing individualized care plans
Helping connect members with resources and services
Completing required documentation
Collaborating with primary care teams to ensure high quality team-based care
Use utilization management tools to facilitate appropriate transitional care management
Collaborate with hospitals, rehabs, and SNFs to manage patient’s inpatient stay and desired discharge plan
Communicate effectively with internal and external stakeholders in order to promote Bluestone’s core values
Help reduce unnecessary visits to the emergency departments as to acute settings with the goal of reducing utilization and unnecessary costs
Work to increase coordination of care for a vastly complex geriatric population
Be proficient in community resources
Proactively engage with providers to identify high risk patients

Qualifications:Education/Certification/Experience

Licensed Social Worker or Registered Nurse
3-5 years of experience in case/care management or care coordination
Experience working directly with the Dementia population required
Formal training in Dementia from a credible organization (i.e. Certification as a Dementia Practitioner) is highly sought
Valid driver’s license required

Knowledge/Skills/Abilities