About this role
Job summary
Shipston Medical Centre is seeking an organised, compassionate and digitally confident Care Coordinator to join our friendly, forward-thinking GP practice. This is a newly developed ARRS role focused on supporting proactive, coordinated care for people with long-term conditions, medication monitoring needs and additional vulnerabilities.
The post holder will help coordinate recall and monitoring processes, support vulnerable groups such as housebound people, care home residents, people with learning disabilities and carers, and help patients navigate reviews, blood tests, follow-up and access to care. They will also support the safe use of digital systems such as EMIS, Abtrace, AccuRx and BetterLetter where these systems affect care coordination, patient access, safety or service continuity.
This is not a clinical role or a general IT technician role. It would suit someone who is highly organised, confident with digital systems, calm under pressure and motivated by improving patient care and practice processes.
We are a CQC Outstanding practice serving a predominantly rural community in the North Cotswolds. We are the only GP practice in Shipston-on-Stour, with an excellent local reputation, a supportive patient population and a friendly, family-like team culture.
Main duties of the job
1. Care Coordination and Patient Support
2. Recall, Medicines Monitoring and Long-Term Condition Coordination
3. Support for Vulnerable Patient Groups
4. Digital Systems Coordination
5. Digital Training and Practice Support
6. Communication and Patient Engagement
7. Quality Improvement, Data and Reporting
8. Team Working and Professional Boundaries
About us
Shipston Medical Centre is a friendly, forward-thinking and innovative GP practice serving a predominantly rural community in the North Cotswolds.
We are the only GP practice in the market town of Shipston-on-Stour and have an excellent reputation within our local community. Our patient population is generally very supportive, and the practice has a strong relationship with the people it serves.
We are CQC rated Outstanding and are proud of our supportive, family-like team culture. We have recently developed a new purpose-built suite of GP consulting rooms and a newly refurbished administrative area, creating an improved environment for both patients and staff.
The practice is highly active in its use of technology to improve patient care. We use systems such as EMIS, Abtrace, AccuRx, BetterLetter and other digital tools to support recall, communication, workflow management and safer, more proactive care.
Job description Job responsibilities
Purpose of the Role
The purpose of the role is to support proactive, coordinated and personalised care for patients, particularly those who may otherwise be at risk of being missed by routine systems.
The post holder will:
support care coordination for patients with long-term conditions and medication monitoring needs; help identify patients who require additional support, follow-up or navigation; support vulnerable patient groups, including housebound patients, care home residents, patients with learning disabilities or other disabilities, and carers; help improve the accuracy of relevant clinical coding; support the practice's transition from Ardens-based recall processes to Abtrace; help develop safe workflows, SOPs and protocols for recall, non-responder management and escalation; work with clinicians, pharmacists, nurses, administrative teams, social care and community services where appropriate; support practice staff in using digital systems safely and effectively in relation to care pathways; help coordinate the practice response when key digital systems are disrupted, to ensure maintenance of patient care; provide advice and practical recommendations to the Operations Lead and partners on digital workflow issues affecting care coordination, access, safety or efficiency.
Main Duties and Responsibilities
1. Care Coordination and Patient Support
The post holder will help coordinate care for patients who need proactive support, monitoring or follow-up.
Duties will include:
Supporting patients with long-term conditions, medication monitoring needs and complex care requirements. Helping identify patients who may need more personalised support than standard automated recall. Contacting patients, carers or care homes where appropriate to help arrange reviews, blood tests, monitoring or follow-up. Helping patients understand what review or monitoring is needed and how to access it. Supporting patients who may struggle to use digital booking links, automated recall or standard appointment systems. Escalating clinical concerns, safeguarding concerns or access difficulties to the appropriate clinician or manager. Liaising with GPs, nurses, pharmacists, social prescribing colleagues, care homes, carers, community teams and social care professionals where appropriate. Supporting patients and carers with navigation through practice processes where this improves access, safety or continuity. Maintaining accurate records of relevant contacts and actions.
2. Recall, Medicines Monitoring and Long-Term Condition Coordination
The post holder will help support the practice's recall and monitoring systems.
Duties will include:
Supporting the implementation and ongoing use of Abtrace. Helping the practice move from Ardens-based recall processes to Abtrace workflows. Supporting recall processes for chronic disease reviews, medication monitoring and planned blood tests. Monitoring recall lists and identifying patients who are overdue or have not responded. Helping ensure appropriate appointment availability for recall and monitoring work. Working with nursing, pharmacy and administrative teams to coordinate recall activity. Supporting medication monitoring workflows, including shared care monitoring where appropriate. Helping reduce duplicated or fragmented recall activity. Supporting the development of SOPs and protocols for recall, non-responder management and escalation. Identifying where recall processes are not working effectively and suggesting improvements.
3. Support for Vulnerable Patient Groups
A key part of the role will be helping the practice identify patients who may need more proactive or personalised care.
Duties will include:
Supporting improved coding and identification of housebound patients. Supporting accurate coding and identification of care home residents. Supporting improved identification and coding of carers. Supporting coordination for patients with learning disabilities and other disabilities. Identifying patients who may not respond to standard digital recall methods. Helping develop workflows for patients who need additional contact, carer involvement or professional coordination. Supporting the practice to target additional care, communication and compassion towards patients who are more vulnerable or less able to navigate standard systems. Working within agreed protocols to ensure concerns are passed to the right clinician, team or external professional.
4. Digital Systems Coordination
The post holder will provide practical coordination and oversight for digital systems used within the practice in relation to the coordination of care.
Duties may include:
Developing a strong working knowledge of key practice systems including EMIS, Abtrace, AccuRx and BetterLetter. Acting as a local point of contact for digital workflow queries within the practice. Helping coordinate the practice response when key clinical or operational systems are disrupted, for example EMIS downtime, to ensure maintenance of patient care. Supporting the development and maintenance of downtime processes and communication plans. Liaising with external IT support, suppliers or system providers where appropriate. Helping staff understand changes to digital systems and workflows in relation to care pathways. Supporting training for practice staff when systems or processes change. Helping create simple guides, SOPs and training materials. Identifying recurring digital workflow problems and suggesting practical solutions. Advising the Operations Lead and partners on digital system issues affecting patient care, safety, access or efficiency. Helping ensure digital processes are safe, consistent and understood across the practice.
5. Digital Training and Practice Support
The post holder will help improve confidence and consistency in the use of practice systems.
Duties may include:
Supporting staff training on agreed digital workflows. Helping new staff understand relevant digital systems. Producing quick-reference guides or process notes. Helping identify where staff need further training or support. Supporting implementation of new systems or major workflow changes. Helping ensure changes are communicated clearly to affected teams. Working with leads and managers to ensure systems are used consistently. Supporting learning from digital incidents, system outages or workflow failures.
6. Communication and Patient Engagement
The post holder will support clear communication with patients and carers, particularly where this relates to recall, monitoring, vulnerable patient groups or access to care.
Duties may include:
Supporting patient-facing communication about recall and monitoring processes. Helping draft clear SMS, email, website or written messages. Supporting communication campaigns linked to long-term condition reviews, medicines monitoring or patient access. Helping ensure communication is accessible to patients and carers. Supporting communication with care homes, carers and other professionals. Identifying where communication processes are not working well and suggesting improvements.
7. Quality Improvement, Data and Reporting
The post holder will support the practice in using data and digital systems to improve care.
Duties may include:
Reviewing recall dashboards, reports and patient lists. Identifying patterns in overdue monitoring, non-response or coding gaps. Supporting audits linked to recall, medicines monitoring, patient cohorts or digital workflows. Helping monitor whether recall systems are working as intended. Supporting quality improvement projects linked to patient access, safety, coding or continuity. Producing simple reports or summaries for managers and clinicians where required. Helping identify practical improvements from day-to-day system use.
8. Team Working and Professional Boundaries
The post holder will work closely with clinical, administrative and operational teams.
Duties will include:
Working collaboratively with GPs, nurses, pharmacists, administrators and managers. Supporting joined-up working between clinical and non-clinical teams. Attending relevant meetings and training. Working within agreed protocols and escalation routes. Recognising the limits of the role and not giving clinical advice unless specifically trained and authorised. Escalating clinical, safeguarding or operational concerns appropriately. Maintaining confidentiality and information governance standards at all times.
Training and Development
The practice will support the successful candidate with:
Care Coordinator training in line with ARRS requirements. Training in personalised care and care navigation principles. System-specific training, including EMIS, Abtrace, AccuRx and BetterLetter. Information governance and safeguarding training. Support to develop skills in recall management and population health. Support to develop skills in digital systems coordination and staff training. Ongoing supervision from the Operations Lead, management team and clinical partners.
The role is expected to evolve as the practice develops its recall, medicines monitoring, chronic disease management and digital systems.
Person Specification
Experience Essential
Experience in an administrative, coordination, healthcare, care, operational or customer-facing role. Experience using digital systems confidently in day-to-day work. Experience communicating professionally with a range of people. Experience managing competing priorities and working to deadlines. Experience following processes accurately and maintaining records. Experience helping others understand or follow a process.
Additional criteria Essential
Successful candidate must be willing to undertake Care Coordinator training and other role-specific training, work within agreed protocols and escalation routes, maintain confidentiality and information governance standards, and work flexibly across practice sites according to operational need.
Qualifications Essential
Good general standard of education, including English and Maths. Confident IT and keyboard skills. Willingness to undertake Care Coordinator training and other role-specific training.
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details Employer name Shipston Medical Centre
Address Shipston Medical Centre
Badgers Crescent
Shipston on Stour
Warwickshire
CV36 4BQ
United Kingdom
Employer's website https://www.shipstonmc.warwickshire.nhs.uk/ (Opens in a new tab)