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PCN Care Coordinator

Dyddiad hysbysebu:	31 Gorffennaf 2025
Cyflog:	Heb ei nodi
Gwybodaeth ychwanegol am y cyflog:	Negotiable
Oriau:	Llawn Amser
Dyddiad cau:	17 Awst 2025
Lleoliad:	Luton, LU33EP
Cwmni:	NHS Jobs
Math o swydd:	Cytundeb
Cyfeirnod swydd:	W0030-25-0002

Crynodeb

Job Description - Hatters Health PCN Care-Coordinator Job TitlePCN Care-Coordinator Responsible toPCN Business Manager Accountable toPCN Clinical Director Hours of work37.5 Hours per week, 1 year fixed term Salary TBC Purpose of the role Care Coordinators play an important role within a PCN to proactively identify and work with people, including those with long-term conditions, cancer, and frailty to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care coordinators review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. The successful candidate will be based at Sundon Park Health Centre, Tenth Avenue, Luton. This is the Hub for Hatters Health PCN a Network of five friendly pro-active practices. They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to support the effective delivery of enhanced access as well as focusing on the PCNs Cancer related objectives. Please note that the role of a care coordinator is not a clinical role. Key responsibilities To support the efficient delivery of enhanced access by supporting daily operational delivery. Ensuring adequate staffing and ensuring a proactive approach to booking appointments. To support data gathering for monthly reporting on enhanced access Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Explore and assist people to access a personal health budget where appropriate. Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies Identify unpaid carers and help them access services to support them Maintain records of referrals and interventions to enable monitoring and evaluation Support practices to keep care records up to date by identifying and updating missing or out-of-date information Contribute to risk and impact assessments, monitoring and evaluations of the service Work with PCN Manager to further develop the role. Key Tasks Rota management for enhanced access delivery Gather data for regular reporting of enhanced access activity To identify rota anomalies and escalate to appropriate colleagues To support delivery of cancer project outcomes Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation To take referrals for individuals or proactively identify people who could benefit from support through care coordination Proactively identify patients who would benefit from improved quality of care provision/ long term condition management Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly Support people to develop, implement and review personalised care and support plans, with activity recorded using the relevant SNOMED codes within patient records Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system Refer onwards to social prescribing link workers and health and wellbeing coaches where required Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported Actively participate in multidisciplinary team meetings in the PCN as and when appropriate Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views Act as a champion for personalised care and shared decision making within the PCN Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities Work in accordance with the practices and PCNs policies and procedures Contribute to the wider aims and objectives of the PCN to improve and support primary care