Care coordinator

Job description

Job responsibilities

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 discussions

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

Person Specification

To have excellent IT skills, to include Microsoft Office, Outlook and Excel

Essential

• Highly responsible, reliable, and organised
• Strong attention to detail with a commitment to accuracy
• Excellent communication and interpersonal skills
• Proven ability to work both independently and as part of a team
• Adaptable and willing to learn new systems and processes
• Proficient in the use of IT systems, particularly those related to healthcare or data management
• Discreet and professional, with a mature approach to handling sensitive information

Experience

Essential

• To have excellent IT skills, to include Microsoft Office, Outlook and Excel

Qualifications

Essential

• GCSE grade A to C in English and Maths

Employer details

Employer name

Hampstead Group Practice

Address

The Hampstead Group Practice

75 Fleet Road

London

NW3 2QU

Employer's website

http://www.hampsteadgrouppractice.co.uk/ (Opens in a new tab)