Care Coordinator, LSW (MSHO)

Bluestone Physician Services
St. Paul, MN
HybridCareer-pivot friendly

Who this role is best for

Geared toward licensed social workers or nurses with experience in geriatric care, comfortable with managing complex chronic conditions and coordinating community-based visits.

Best fit for

  • Licensed social workers or nurses with a track record in geriatric care and community-based service delivery
    — “Current MN Licensed Social Worker (LSW, LMSW, LISW, or LICSW) - New grads encouraged to apply!”
  • Candidates who value proactive, preventative care and have a passion for supporting seniors in their homes
    — “help members remain safely in their homes and communities”
  • Individuals who are detail-oriented and capable of managing documentation and compliance requirements
    — “Completing required documentation”

Things to consider

  • The role requires regular local travel for in-person visits, which may affect work-life balance
    — “50–70% local community visits”
  • Candidates must have a valid driver’s license to fulfill travel requirements
    — “Must have a valid driver’s license”

How to stand out

  • Highlight experience with DHS and CMS requirements in your resume and interviews
    — “manage Department of Human Services (DHS) and Center for Medicare/Medicaid Services (CMS) requirements”
  • Emphasize your ability to develop individualized care plans and support behavioral health
    — “Reviewing current health needs, identifying goals, and developing individualized care plans”
  • Showcase your communication and interpersonal skills, especially with diverse populations
    — “Appreciation for working with diverse populations”
  • Demonstrate your experience with managing transitions of care and discharge planning
    — “Supporting members during transitions of care as well as collaborating with their care team to ensure a safe discharge and follow up plan”
Pace · SteadyCollaboration · HighAutonomy · MediumDecision Impact · Individual

Derived from job-description analysis by Serendipath's career intelligence engine.

What success looks like

  • Manage member caseloads within assigned geographic area
  • Help members remain safely in their homes and communities
Typical background
LSW (MSHO) certification

Skills & requirements

Required

Care CoordinationElderly Waiver ManagementAnnual AssessmentsHealthcare Quality MeasuresUtilization ManagementTransitions Of Care

Preferred

Behavioral Health SupportSocial Determinants Of Health

Stack & domain

Care CoordinationMSHODHSCMSCommunicationCollaborationChronic ConditionsDisabilitiesPrimary CareBehavioral Health

About the role

Original posting from Bluestone Physician Services via Greenhouse

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 — St. Paul and Roseville areas (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 visits

Managing the Elderly Waiver

Conducting annual assessments including Personal Care Assistance (PCA) assessments for community members and customized living tools for members residing in Assisted Livings

Reviewing current health needs, identifying goals, and developing individualized care plans

Helping connect members with community and state resources and services

Help members remain safely in their homes and communities

Completing required documentation

Collaborating with medical care teams to ensure health care quality measures are met and use utilization management tools to meet value-based goals

Supporting 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 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:

Education/Certification/Experience

Current MN Licensed Social Worker (LSW, LMSW, LISW, or LICSW) - New grads encouraged to apply!

OR Minnesota Registered Nurse license

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

Knowledge/Skills/Abilities

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

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

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​

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Pay Transparency$65,000—$75,000 USD

Source: Bluestone Physician Services careers (Greenhouse)

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