About this role
Job summary
We are looking to expand our Care Co-ordinators team, you will be responsible for supporting the practice in delivering excellent patient care by effectively co-ordinating different elements of care from multi-disciplinary teams within the practice.
The post holder will be the first point of contact for patients and relatives in case their needs change. Many patients have complex highly complex needs and would need support in coordinating with relevant services. The Care coordinator will support the patient with their needs and find the relevant services.
Main duties of the job
Role Purpose: Provide extra capacity and structure to support patients, manage a caseload, and coordinate care across GP practices, social care, and community services. Key Working Relationships: GPs, practice nurses, reception/admin teams, pharmacy teams, Social Prescribing Link Workers, and Health and Wellbeing Coaches. Core Duties & Responsibilities
Patient Navigation & Caseload Management: Proactively identify and manage a caseload of patients (such as the frail, elderly, or those with long-term conditions). Recall & Reviews: Coordinate and send out invitations for patient annual health reviews and manage Quality and Outcomes Framework (QOF) targets. Communication Hub: Act as a central point of contact and communication between patients, families, carers, and clinical/non-clinical teams. Service Signposting: Help patients navigate local health, social care, and voluntary/third-sector services. Administrative & Data Support: Track referrals, update patient care records, handle practice emails/triage tools (like AccuRx), and assist with data collection.
About us
Bridge Surgery is a very friendly, supportive, well organised GMS training practice with:
10,000 patients 4 Partners, 3 Salaried GPs and GP Trainees SystmOne High QOF achievement CQC good in all areas
Job description Job responsibilities
The following are the core responsibilities of the role. There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:
Utilise both internal and external population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
To undertake Personalised Care Training commensurate with the role.
Support patients to utilise decision aids in preparation for a shared decision-making conversation.
Holistically bring together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP).
Help patients 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 patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.
Co-ordinate the delivery of the Multi-Disciplinary Team Meetings within the Practice, Care Homes and external providers.
Work with the GPs and other primary care professionals to identify and manage a caseload of patients and where required/appropriate, refer patients onto to other health professionals.
Build and maintain effective professional relationships with the MDT and create a network of contacts to assist the MDT in providing the most effective package of patient care.
Schedule and organise MDT meetings, liaising with key members of the team. Manage all administrative duties to include preparation and distribution of agenda items and the taking and distributing of meeting minutes and action plans.
Take responsibility for co-ordinating the actions arising from the meetings ensuring that this is carried out in a timely, effective and coherent manner.
Ensure that all patients Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensuring relevant information is available.
Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with the primary care team.
Act as a conduit between the Practice Clinical Team and the external Care Homes, providing first line support and guidance and ensuring an effective and efficient package of support is provided to our Care Homes patients. This includes ringing the care homes on a weekly basis.
Assist in the identification of housebound patients, work with the primary care team and social prescriber to ensure that the package of care provided to this cohort suits the individual needs of the patient.
Support with QOF outputs for the year and any other areas within PCN.
Maintain the various long term condition registers, update as necessary and send the associated recall letters.
Maintain the cervical cytology system, check routine cytology recall lists, input results and send appropriate recall and referral letters.
Send reminder, invitation and ad-hoc letters to patients as required/appropriate.
Construct and maintain templates in conjunction with clinical staff.
Monitor and action all e-mails sent to the generic surgery e-mail account throughout the day as per our protocol.
Carrying out searches and interrogating the system to provide necessary audits and reports, on both a periodic and ad hoc basis as required by the management and clinical teams.
Read coding of information into the practice clinical system consistently, accurately and in a timely manner to ensure safe practice as required.
Check GP pathology results each morning, matching unmatched patient results and allocating any unallocated results. Share out the results of GPs not on duty that day.
To drive wellbeing within the practice with Staff and patients.
Other duties as agreed with the Partnership.
This Job Description is not exhaustive and duties may vary from time to time dependent upon the requirements of the business.
Person Specification
Experience Essential
Qualifications & Knowledge Education: GCSE or equivalent Grade C or 4 or above in Maths and English. Training: Enrollment in or completion of training aligned with the Personalised Care Institute core curriculum. System Knowledge: Familiarity with GP patient administration systems e.g., Emis, SystmOne and Microsoft Office applications. Experience Minimum of 1 year of experience working with healthcare professionals or in a health/social care setting. Experience coordinating and liaising with multiple stakeholders or managing patient pathways. Experience providing guidance, advice, or signposting to service users. Personal Qualities & Skills Communication: Strong verbal and written communication skills with high levels of empathy and active listening. Organization: Ability to plan, prioritize, and manage a busy workload independently under pressure. Teamwork: Ability to work flexibly and collaboratively within a multidisciplinary team. Discretion & Compliance: Knowledge of confidentiality, safeguarding, information governance, and health and safety policies.
Desirable
Working in Primary Care
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 Bridge Surgery
Address St Peters Street
Stapenhill
Burton on Trent
Staffordshire
DE15 9AW
United Kingdom
Employer's website https://www.bridgesurgery.net/ (Opens in a new tab)