BRUNEL PCN - Care Coordinator

• Maintain and manage registers of patients identified as being at increased risk, ensuring information is accurate and up to date.
• Support the Integrated Neighbourhood Team in identifying patients requiring proactive follow-up and coordinating their care.
• Provide administrative and coordination support to ensure effective delivery of proactive and responsive care.
• Liaise with patients, carers, practice teams and wider healthcare professionals to support continuity of care.
• Support the coordination of care for frail, housebound, palliative and clinically vulnerable patients.

• Support appointment management, particularly for the Same Day Acute Visiting Service, ensuring appointments are coordinated efficiently.
• Contact patients and carers by telephone to arrange appointments, home visits and follow-up care.
• Assist with the organisation and coordination of clinical activity to ensure effective use of available appointments and resources.
• Support communication between clinicians, practices and patients to facilitate timely care.

• Support the organisation and coordination of Long-Term Condition (LTC) management, including assisting with patient lists, recalls, appointments and monitoring activity.
• Coordinate and arrange Gold Standards Framework (GSF) meetings, including scheduling meetings, preparing patient lists and ensuring relevant information is available to the clinical team.
• Support the recording and follow-up of actions arising from GSF and multidisciplinary team meetings.
• Assist with maintaining accurate patient registers to support proactive care planning and clinical reviews.

• Assist with the collection, extraction and collation of clinical and service data to support reporting, monitoring and service development.
• Support accurate clinical coding and record keeping on SystmOne, ensuring patient care and interventions are appropriately documented.
• Assist with monitoring activity and maintaining accurate records to support service delivery and reporting requirements.
• Maintain confidentiality and ensure all patient information is handled in accordance with information governance requirements.
• Provide general administrative and organisational support to the Integrated Neighbourhood Team as required.

Desirable

• Experience working within primary care or an NHS setting
• SystmOne experience
• Experience of appointment management or patient recalls
• Experience maintaining patient registers or clinical data
• Experience supporting LTC management
• Experience organising MDT or GSF meetings

Essential

• Good general IT skills and confidence using computer systems
• Ability to prioritise competing demands
• Excellent verbal and written communication skills
• Professional and compassionate telephone manner
• Ability to communicate sensitively with vulnerable patients
• High level of accuracy and attention to detail
• Ability to work independently and within a multidisciplinary team
• Understanding of confidentiality and information governance
• Ability to adapt to changing service priorities