In-Home Chronic Care RN | Primary Care Team

Mayo Clinic; Spring Valley (MN); On-site; USD 49,000 - 81,000; Full time

Benefits offered by this job

Medical plan options

Dental plan

Vision plan

HSA and FSAs

Competitive retirement package

Job summary

Mayo Clinic in Minnesota is seeking an experienced Registered Nurse (RN) for Primary Care to support patients with chronic conditions transitioning from hospital to outpatient care. The role emphasizes care coordination, motivational interviewing, and patient education within a specialized nursing team.

The RN will conduct post-hospital follow-up calls, perform in-home visits, and collaborate with primary care providers to implement individualized care plans.

Qualifications

• BSN or higher nursing degree from ACEN/CCNE/NLN CNEA-accredited program or equivalent.
• RN license by state requirements; BLS for certain states; licensure and VisaScreen as required for international assignments.
• One year RN experience in applicable care setting preferred.
• Excellent communication skills and ability to work in a team.
• Ability to work flexible hours including days/evenings/nights/weekends/on-call.

Responsibilities

• Post-hospital follow-up calls for patients at risk of readmission.
• In-home visits for adult medical care coordination after hospital discharge; medication reconciliation and safety evaluation.
• Develop and monitor individualized care plans with primary care providers.
• Manage a defined patient panel with ongoing follow-up and coordination.
• Educate and support patients on chronic conditions and medications.

Skills

RN experience in chronic care

Motivational interviewing

Care coordination

Collaborative care

Leadership

Education

BSN / Bachelor of Science in Nursing

RN license

Tools

Electronic medical record systems

Job description

Mayo Clinic in Minnesota is seeking an experienced Registered Nurse (RN) for Primary Care to support patients with chronic conditions transitioning from hospital to outpatient care. The role emphasizes care coordination, motivational interviewing, and patient education within a specialized nursing team.

The RN will conduct post-hospital follow-up calls, perform in-home visits, and collaborate with primary care providers to implement individualized care plans.