About this role
Job summary
The PCN Care Coordinator plays a key role in supporting patients and staff to navigate health and care services, ensuring they receive timely, coordinated, and person-centred care. Working as part of the multidisciplinary team (MDT), the Care Coordinator will identify and support patients with complex health and social needs, helping to improve outcomes, reduce health inequalities, and ensure effective use of healthcare resources with a strong emphasis on data and using population health management tools.
Main duties of the job
Coordinate care for identified patients, particularly those with long-term conditions, frailty, multiple health needs, or complex social circumstances.
Facilitate communication between practices, community teams, social care providers, secondary care, and voluntary organisations.
Escalate concerns regarding patient wellbeing or safeguarding appropriately.
Use practice and PCN systems to identify patients who may benefit from proactive intervention.
Support delivery of PCN priorities, including:
Anticipatory care. Enhanced health in care homes. Personalised care. Health inequalities initiatives. Long-term condition management. Assist with recall programmes and targeted interventions for vulnerable patient groups.
About us
HASP PCN is a network of five GP practices based in Hull with approx 35,000. This role is part of a multi-disciplinary team supporting the ongoing care of our patients across all practices.
Job description Job responsibilities
Job Description: PCN Care Coordinator
Job Title
Primary Care Network (PCN) Care Coordinator
Reports To
PCN Manager / Clinical Director
Accountable To
Primary Care Network Board and Host Practice
Hours
Full-time or part-time (as agreed)
Salary
Dependent on experience and local terms and conditions (typically aligned to NHS Agenda for Change equivalent banding).
Job Purpose
The PCN Care Coordinator plays a key role in supporting patients and staff to navigate health and care services, ensuring they receive timely, coordinated, and person-centred care. Working as part of the multidisciplinary team (MDT), the Care Coordinator will identify and support patients with complex health and social needs, helping to improve outcomes, reduce health inequalities, and ensure effective use of healthcare resources with a strong emphasis on data and using population health management tools.
Key Responsibilities
Care Coordination
Coordinate care for identified patients, particularly those with long-term conditions, frailty, multiple health needs, or complex social circumstances. Monitor patient progress and ensure actions agreed through MDT meetings are completed. Maintain regular contact with patients and carers to provide ongoing support and reassurance. Empower patients to take an active role in managing their health and wellbeing. Support patients to understand care plans, appointments, referrals, and treatment pathways. Assist with addressing barriers to accessing healthcare services. Attend and contribute to MDT meetings. Facilitate communication between practices, community teams, social care providers, secondary care, and voluntary organisations. Escalate concerns regarding patient wellbeing or safeguarding appropriately. Use practice and PCN systems to identify patients who may benefit from proactive intervention. Support delivery of PCN priorities, including: Anticipatory care. Enhanced health in care homes. Personalised care. Health inequalities initiatives. Long-term condition management. Assist with recall programmes and targeted interventions for vulnerable patient groups. Administration and Record Keeping
Maintain accurate and timely patient records using clinical systems. Record interventions and outcomes in line with PCN requirements. Produce reports and performance information as required. Manage caseloads effectively and prioritise workload appropriately. Safeguarding and Governance
Adhere to safeguarding policies and procedures for adults and children. Maintain confidentiality and comply with GDPR and NHS information governance requirements. Report incidents, concerns, and risks according to organisational policies. Participate in audit, quality improvement, and service evaluation activities.
Key Working Relationships
The post holder will work closely with:
GP Partners and Salaried GPs PCN Clinical Director PCN Manager Practice Managers Advanced Clinical Practitioners Social Prescribing Link Workers Health and Wellbeing Coaches Clinical Pharmacists Care Home Teams Community Nurses Mental Health Practitioners Adult Social Care Voluntary, Community and Social Enterprise (VCSE) organisations Patients, families, and carers
Person Specification
Essential Qualifications
Educated to GCSE level (or equivalent) including English and Mathematics. Strong written and verbal skills Essential Knowledge and Experience
Experience of working within health, social care, community, or customer service settings. Understanding of patient-centred care and multidisciplinary working. Experience of managing caseloads and coordinating activities. Experience of communicating with a range of stakeholders. Understanding of confidentiality and information governance requirements. Essential Skills
Excellent communication and interpersonal skills. Ability to build relationships with patients and professionals. Strong organisational and time management skills. Ability to prioritise workload and work independently. Competent IT skills, including Microsoft Office and clinical systems. Accurate record-keeping and administrative skills. Desirable Criteria
Experience working within Primary Care, NHS, or PCN settings. Knowledge of local health and care pathways. Experience supporting vulnerable populations. Knowledge of personalised care approaches. Understanding of population health management principles. Experience using SystmOne, EMIS Web, or other NHS clinical systems.
Key Performance Indicators (KPIs)
The Care Coordinator may be expected to contribute towards:
Increased uptake of preventative healthcare services. Improved patient experience and satisfaction. Reduction in unplanned hospital admissions. Improved management of patients with long-term conditions. Completion of MDT actions within agreed timescales. Reduction in health inequalities across the PCN population. Achievement of PCN service specifications and contractual requirements.
Values and Behaviours
The post holder will be expected to demonstrate:
Compassion and respect. Integrity and professionalism. Commitment to high-quality patient care. Collaborative working. Equality, diversity, and inclusion. Continuous learning and improvement.
Person Specification
Skills Essential
This role includes working from various sites around the city. Candidates must have the means and ability to work from multiple locations.
Desirable
Experience of using clinical systems - ideally SystmOne
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 KINGSTON HEALTH
Address Park Health Centre
HULL
HU9 3JA
United Kingdom
Employer's website http://www.kingstonhealthhull.nhs.uk/ (Opens in a new tab)