Serves in an expanded nursing role to collaborate with members and care team to ensure high risk members are provided personalized care coordination services. Provides panel management for the most complex members. Ensures members/caregivers have the resources and ability to thrive at home with education and access to the appropriate care for their required health condition. Works closely with the Primary Care Teams to build a model of care for those who would benefit from proactive complex care coordination. Integrates evidence based clinical guidelines, protocols, and other metrics in the development of treatment and care plans focused on patient centered goals of care. Promotes quality and efficiency in the delivery of the targeted high risk population. Promotes optimum clinical outcomes and builds trusting relationships with our members to positively impact utilization of resources, palliative care services and better health.

• This position, knows and complies with all Kaiser Permanente quality, safety, and emergency policies and procedures. Demonstrates quality and effectiveness in work habits and clinical practice in every interaction with patients, colleagues, providers, and leadership. Ensures patient safety in the preparation and provisioning of care related to but not limited to medications including the consistent use of 5 rights and 3 checks of medication administration, procedures, infection prevention, fall prevention, including consistent use of two patient identifiers and procedural time outs. Reports safety hazards, accidents and incidents, and unsafe working conditions promptly.


• Maintains a panel of patients that are identified by risk stratification at the local MOB. Provides a point of contact for these complex members.


• Assesses the healthcare, educational, and psychosocial needs of the member/caregiver and develops an appropriate care plan.


• Provides culturally relevant education and teach back for members that are enrolled into the RNCC panel.


• Synthesizes data from multiple sources including phone and face to face interaction with members to develop a coordinated patient plan of care and implements in collaboration with providers and multidisciplinary teams.  


• Synthesizes and analyzes a large volume of data related to the member, benefits, eligibility, facilities, contracts, and clinical status to identify issues and facilitate problem solving that results in continuity of care, quality of care and optimal resource management for the patient.


• Develops strong relationships of trust, effective interpersonal skills, and communication in a collaborative environment with CPMG and network providers, leaders, and colleagues.


• Analyzes reports and records data. Uses data to identify health care problems and creates plan.


• Prioritizes patients needs. Triages patients either in person or via telephone and implements proper course of action in accordance with established protocol/guideline or in consultation with provider. Conducts telephone call backs to patients requiring follow-up care. Evaluates emergency situations and initiates appropriate nursing interventions.


• Executes delegated medical functions which deliver aspects of care that implement and are consistent with the medical plan as prescribed by a licensed or otherwise legally authorized physician or person acting under the physicians delegated authority. Administers intravenous therapy and other medications.


• Provides therapy and treatment that is supportive and restorative to life and well being either directly to the patient or indirectly through consultation with, delegation to (per Colorado State Board of Nursing rules and regulations for delegation), supervision of, or teaching others. Refers to medical or community agencies per Kaiser Permanente guidelines those patients who need further treatment, evaluation, or assistance. Reviews and monitors therapy and treatment patient plans. Initiates appropriate consultations and/or actions accordingly.


• Facilitates the coordination and integration of care between health care services. Manages populations of patients to ensure appropriate utilization of health care resources. Leads health care team by influence and role modeling integrated effective nursing practices, services, innovation and provides outstanding support for physician practices.


• Acts as a patient advocate.