Job Description

Guide Model Dementia Care Navigator

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 Tribunes Top Workplace list for the 12th year in a row! Bluestone also achieved Top Workplace USA 2021-2024! 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

As Guide Model Dementia Care Navigator . 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 direct patient care mainly throughout Venice, North Port, Port Charlotte areas Salary Range: $65,000 - $75,000, Salary will be commensurate with experience

Responsibilities

• 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 patients inpatient stay and desired discharge plan
• Communicate effectively with internal and external stakeholders in order to promote Bluestones 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

• Degree in Social Work, 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 drivers license required

Knowledge/Skills/Abilities

• Ability to work independently
• Strong customer service, relationship building, and communication skills
• Strong technical skills and experience with EHRs preferred
• Demonstrated compatibility with Bluestones purpose, focus and values
• Ability to travel throughout the market area as needed
• 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
• Eight (8) paid holidays for office closures plus two (2) floating holidays
• Three weeks (15 Days) Paid Time Off (PTO)
• Mileage reimbursement program for field employees
• Company sponsored cell phone, laptop and scrubs
• Regular business hours

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