The Population Health Care Coordinator (PHCC) is a registered nurse who independently assesses the needs of members with chronic conditions to direct care, via phone or on-site, as needed throughout the region. This position works under varying schedules throughout locations to meet the needs of the patient, clinicians and staff to assure smooth transitions  and appropriate, timely level of care and service. The PHCC applies assessment information in referring members to appropriate teams and departments and serves as an expert resource regarding KPNW services. PHCC services are available for members with a variety of complex chronic conditions such as Trauma, Transplants, Rehabilitation, Diabetes Mellitus, Hepatoma or Hepatoma Risk, Abdominal Aortic Aneurysm, Pain and other conditions. This position has responsibility to collaboratively design and develop integrated systems, processes, and communications to support the monitoring and care of patients in focused populations defined by KPNW. The PHCC plans, directs, and oversees clinical service delivery for individuals at risk, in order to assure high quality, cost-effective clinical outcomes within the framework of patient-centered care delivery. The role of the PHCC is to improve coordination and patient engagement while utilizing best/evidence-based practices to support regional priorities. This position directs patient care needs across the ambulatory and inpatient (KSMC, Plan and other hospitals) care settings, and community services, to insure optimum care for members in defined KPNW priority populations.

• Design and develop a process of identifying patients in need of ongoing surveillance, tracking and screening for the development of further complications and follow-up in partnership with the physician mentor and Quality leadership. Coordinates with patients, families, and health care teams to develop a mutually agreeable plan of care that meets the needs of the individual member.


• Research the healthcare environment for innovative concepts and best practices, assimilate and comprehend the evidence, and work within Quality Improvement and Department structures to develop practical applications for the program. Responsible for the planning, oversight, implementation and coordination of programs and processes in assigned area of responsibility. Takes independent action and accountability for achieving successful results.


• Coordinate services for the patient population having a health risk or chronic condition to include: screening and on-going monitoring of patients, i.e., at risk for hepatocellular carcinoma (HCC), Glycemic Control, Trauma, Transplant, Opioid Use etc. Supervises the appropriate delivery of quality care.


• Reviews referrals for members with complex chronic conditions such as Diabetes Mellitus, Liver Cirrhosis/Hepatitis B/C, Trauma, Transplant, Rehabilitation, Pain, etc, and delegates to, or coordinates care with the appropriate health care team (Primary Care, NISP, DMCM, MMP, HES, Nutrition Services, Specialty Care Coordinators, Virtual Hospitalist, GI, Oncology, Addictions, Metal Health, Pain Clinic, etc.) for high quality follow-up and/or intervention. Responsibilities include timely review of the members current clinical and psychosocial status, assessment of member readiness for change and formulation & documentation of a patient-centered plan of care.


• Formulates patient-centered care plans with the patient, family, and other teams while educating the patient, family, and health care team about options and alternatives. Completes all necessary documentation for referrals and handoffs between care settings to ensure a seamless transition to other levels of care.


• Serves as a clinical resource to staff and clinicians regarding complex chronic care situations. Covers for other Population Health Care Coordinators during absences.