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 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 (https://bluestonemd.com/2023/09/bluestone-aco-delivers-excellent-care-to-medically-complex-elderly-patients-saves-medicare-26-6-million/) as measured by the overall savings per Medicare beneficiary. Position Overview: Join our team as a Transitional Care Manager where you will coordinate acute and post-acute stays and discharges for Bluestone patients in value-based care arrangements. In this role, you will build strong, collaborative relationships with hospital and post-acute providers to ensure patients receive appropriate care and placement throughout their stay. You will partner with Bluestone medical providers, clinical assistants, and care coordinators throughout patient stays to ensure the best communication and quality care possible. The position allows for great work-life balance, with approximately 70% remote and 30% of the time allowing you to meet team members as well as facilitate in person meetings with our 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: (Hybrid) 70% remote, and 30% throughout the greater Milawukee, including Franklin, Waukesha, Oak Creek  areas. Salary: $60k - $70k. Salary will be commensurate with experience. Responsibilities:   + Collaborate with hospitals, rehabs, and SNFs to manage patient’s inpatient stay and desired discharge plan + Manage patient arrangements for stays and discharges + Communicate effectively with internal and external stakeholders in order to promote Bluestone’s mission and maintain patient health + 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 + Use your partnerships to improve collaboration among acute and post-acute settings + Assure patients are receiving the right care, at the right place, and the right time  + Be an expert in community resources that allow for patients to age at home + Proactively engage with providers to identify high risk patients Qualifications: Education/Certification/Experience + Registered Nurse, Social Worker, or LPN with 4-year degree or commensurate experience + 3-5 years of experience in value-based care, population health, case management, care coordination and/or discharge planning highly preferred + 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 mission and operating philosophies + Ability to occasionally 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   Powered by JazzHR