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 servicesour 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 2021-2025! 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 a Guide Model Dementia Care Navigator, 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 Menomonie Falls, Milwaukee, Waukesha areas.

Salary Range: $65,000 - $80,000, 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 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: Registered Nurse or Licensed Social Worker, 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: Ability to work independently, strong customer service, relationship building, and communication skills, strong technical skills and experience with EHRs preferred, demonstrated compatibility with Bluestone's 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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