Registered Nurse - Primary Care- Adult Medical Care Coordination - RN

Location: Baldwin Building

Join a specialized nursing team within Primary Care that supports patients with chronic conditions transitioning from a hospitalization back to Primary Care. This role is well suited for an experienced Registered Nurse (RN) with a background in caring for patients with chronic conditions, such as CHF, COPD, diabetes and others, and/or primary care, and an interest in motivational interviewing, care coordination, and collaborative health care.

Key Responsibilities:

• Post-hospital Follow-up Calls: Conduct post-hospital follow up calls for patients at risk of readmission.
• Home Visits: Conduct in-home visits to patients who qualify for adult medical care coordination following dismissal from a hospitalization. Complete medication reconciliation, symptom assessment, safety evaluation, and patient-centered goal setting.
• Collaborative Care: Partner closely with primary care providers to develop, implement, and monitor individualized care plans that support patient-centered healthcare treatment.
• Panel Management: Manage a defined panel of patients, providing ongoing follow-up, care coordination, and progress monitoring.
• Education and Support: Provide education and support to patients related to their chronic health conditions, treatment plans, and prescribed medications, promoting engagement and informed decision-making with a goal to increase the patient's capacity to care for their chronic conditions.

The registered nurse (RN) is accountable for the coordination of nursing care, including direct patient care, patient/family education and transitions of care. The RN supports professional nursing practice across practice settings and across the continuum of care to meet the needs of the patient and family. The RN will function within the Mayo Clinic Nursing Professional Practice Model, which includes accountability for planning, implementing, evaluating and communicating all phases of nursing care for assigned patients. The ANA Nursing: Scope and Standards of Practice provide a basis for the practice of the RN. The RN provides leadership through activities such as preceptor role, informal and formal leadership roles, and quality improvement efforts. The RN delegates patient care according to skill level, experience, patient acuity, fiscal accountability and availability of resources. The RN possesses excellent communication skills; is skillful in mentoring and teaching; and may participate on committees or projects. A subset of employees may be required to drive their personal vehicle as a part of the responsibility of their role.
This role is eligible for TN sponsorship. Holders of F1 status eligible for post-completion OPT are welcome to apply. This role is NOT eligible to participate in the F-1 STEM OPT extension program. Successful sponsorship will require state licensure and completion of the VisaScreen or equivalent certification.