Kaiser Permanente RN, Population Health Care Coordinator (Portland Regional Process Center) in Portland, Oregon

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.

Essential Responsibilities:

  • 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 comprehendthe 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 andprocesses 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 member's 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.

Basic Qualifications:


  • Minimum two (2) years in recent acute medical setting.

  • Minimum three (3) years of recent experience in areas of case management, care coordination or population-based care.

  • Minimum two (2) years in acute or ambulatory medical care.

  • Minimum three (3) years of recent outpatient experience working with patients with chronic conditions including Diabetes Mellitus, Liver Disease, Trauma, Rehabilitation, or Transplant, Pain etc.


  • BSN required.

License, Certification, Registration

  • Current Oregon and Washington RN license required. License in state where assigned required upon hire/transfer, application for license in secondary state required within 2 weeks of hire/transfer and must be obtained within 6 months.

  • Certification or advanced nursing license in relevant area of specialty within 12 months of hire

  • Valid Driver's License.

Additional Requirements:

  • Excellent written, verbal and interpersonal communication skills. Demonstrated ability to work with a multi-disciplinary team within a complex organizational structure.

  • Demonstrated ability to work independently in an unstructured environment with minimal supervision.

  • Demonstrates clinical nursing and leadership skills.

  • Knowledge of Kaiser Permanente and Community resources for the care of patients with chronic conditions.

  • Ability to present reports verbally in a public setting (public speaking).

  • Demonstrated data entry skills and ability to use Microsoft Word software Knowledge: Case management principles, including population based management, systems framework for organizational assessment and problem-solving.

  • Demonstrated ability to organize, coordinate, and effectively lead multidisciplinary teams to develop and follow-through with patient-centered care plans (leadership). Thorough knowledge of levels of care within outpatient, acute care and extended care settings.

  • Demonstrated data entry skills and ability to use Microsoft Word software Knowledge: Case management principles, include, and extended care settings.

  • Demonstrated understanding of population-based health, population management, and systems framework for quality improvement.

  • Ability to work effectively within an interdisciplinary team.

  • Demonstrates excellent customer-focused service skills.

  • Familiarity with PC environment and ability to use computers.

Preferred Qualifications:

  • Extensive experience in coordinating care for adults with chronic conditions such as Diabetes Mellitus, Liver Disease, or Transplants, Trauma, Rehabilitation, etc.

  • Experience in conducting telephone assessment of patients.

  • Experience of delegation of patient care or case management in a managed care environment.

  • MSRN.

  • Thorough knowledge of the care needs of patients with chronic conditions, including but not limited to Diabetes Mellitus, Liver Disease, Trauma, Transplant, or Rehabilitation, Pain, Heart Disease, etc.

  • Thorough knowledge of the resources available to the member, and the ability to cross reporting structures to recommend changes within and outside of KPNW to increase positive patient outcomes.

  • Thorough knowledge of KPNW clinical operations.


TITLE: RN, Population Health Care Coordinator (Portland Regional Process Center)

LOCATION: Portland, Oregon


External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.