RN - Primary Care Care Coordinator & Home Visits

Mayo Clinic; Pine Island (MN); On-site; USD 74,000 - 122,000; Full time

Benefits offered by this job

Medical plan options

Dental coverage

Vision plan

Pre-Tax Savings: HSA/FSAs

Competitive retirement package

Job summary

Mayo Clinic in Minnesota seeks an experienced registered nurse (RN) to join a specialized Primary Care team that supports patients with chronic conditions transitioning from hospitalization back to Primary Care. This role emphasizes motivational interviewing, care coordination, and collaborative health care.

The RN leads post-hospital follow-up calls, conducts in-home visits for care coordination, and partners with primary care providers to implement patient-centered care plans.

Qualifications

• RN requires a baccalaureate nursing degree (ACEN/CCNE/NLN CNEA pathways described).
• Excellent communication skills (verbal and written).
• Ability to work in a team and adapt to flexible hours.

Responsibilities

• Post-hospital follow-up calls for patients at risk of readmission.
• In-home visits for adult medical care coordination after discharge.
• Collaborate with primary care providers to develop and monitor care plans.
• Manage a defined patient panel with ongoing follow-ups and care coordination.
• Educate patients about chronic conditions and prescribed medications to promote engagement.

Skills

Communication skills

Teamwork

Critical thinking

Mentoring/education

Education

Baccalaureate nursing degree

Tools

EMR systems

Job description

Mayo Clinic in Minnesota seeks an experienced registered nurse (RN) to join a specialized Primary Care team that supports patients with chronic conditions transitioning from hospitalization back to Primary Care. This role emphasizes motivational interviewing, care coordination, and collaborative health care.

The RN leads post-hospital follow-up calls, conducts in-home visits for care coordination, and partners with primary care providers to implement patient-centered care plans.