Care coordinator

Key Duties and Responsibilities: Act as a key point of contact for patients being supported through our specialist services (e.g., respiratory, diabetes, Bangladeshi clinic). Support patients in navigating the health and social care system, including booking appointments, arranging transport, and helping access community support. Coordinate care for patients with complex needs, ensuring their care plans are up-to-date and shared across services. Work closely with our team of GPs, nurses, social prescribers, and community teams to ensure continuity of care.

Identify patients who may benefit from proactive care planning through data searches and multidisciplinary team discussionsAdditional Key Responsibilities: Be responsible for daily updating of patients on e-HealthScope Workflow and identifying potential gaps in care. Proactively prepare any actions prior to the MDT ensuring all relevant clinicians are present. To record patient interventions on relevant electronic database systems (e.g. EMIS Web) and contribute to report generation, analysis and production Follow up on all forward actions resulting from MDT discussions Be responsible for logging and making referrals To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles To be customer (patient, carer, GP) focused when representing the service To work collaboratively with other teams and services to maintain an effective and efficient service To offer appropriate support and guidance to patients and their families/carers To plan / organise work using own initiative, whilst being able to work as a valuable member of a team To have excellent IT skills, to include Microsoft Office, Outlook and Excel To undertake general office duties to support the role To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service To ensure all electronic records are updated and complete within the agreed time-scale To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested Support the PCN team as required Work with key personnel in the PCN to develop & support collective general practice projects including areas of federated working Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care Work closely and in partnership with the Social Prescribing Link Worker(s) To participate in the review and appraisal process To carry out any other reasonable duties as requested by a manager to ensure quality of service To participate in any relevant training/courses/conferences Use clinical systems for record keeping, audit and evaluation Develop and implement data collection systems that will provide accurate and timely dat