Job Description
📋 Description 90% field-based direct patient care across Minnesota communities. Primary liaison between patient, family, and PCP; ensure unified care plan. Develop and manage individualized care plans; support advance care planning. Behavioral health management within CoCM; implement BH interventions. Lead transitions from hospital/rehab to prevent 30-day readmissions. Collaborate with MD/NP/PA to update care strategies as status evolves. 🎯 Requirements Bachelor's degree or higher; licensed LPN/RN/Social Worker preferred. 3-5 years in value-based care, population health, case management, or discharge planning. Behavioral health experience preferred. Knowledge of Assisted Living and Memory Care communities. Strong time management and ability to work independently. Proficient with EHRs and standard office software. 🎁 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)
