About this role
Job summary
About the Role
South one PCN Newham is seeking a highly organised and motivated individual to join our team as an MDT coordinator, care coordinator and integrated care lead
This is an exciting opportunity to play a key role in delivering proactive, integrated care for patients with long term conditions (LTCs). You will lead on coordinating Multi-Disciplinary Team (MDT) working and ensuring effective clinical care coordination across services, helping improve patient outcomes and reduce health inequalities.
You will work closely with GP practises, community services, social care, and voluntary sector partners to ensure care is joined-up, person-centred and proactive, in line with the LTC Proactive Care Quality and Outcome Framework (QOF).
Main duties of the job
Key responsibilities
Alternate and support effective MDT meetings across S 1 PCN, ensuring they are well structured, outcome focused, and aligned with QOF requirements.Provide clinical coordination for patients with complex, long-term conditions, ensuring timely follow-up and continuity of care.Act as a central link between primary care, community services, social care, and voluntary organisations.Support identification and proactive management of patients with high levels of need.Ensure personalised care plans are developed, implemented, and reviewed.Promote integrated, person-centred care that addresses physical, mental, and social needs.Contribute to reducing health inequalities and improving access for undeserved populations.Monitor MDT activity and contribute to quality improvement and performance reportingSupport delivery and assurance of LTC Proactive care QOF requirements.We are looking for someone who:Has experience in MDT coordination and/or clinical care coordination within the NHS, primary care, or community services.Has a strong understanding of long-term condition management and integrated careIs highly organised, proactive, and able to manage complex patient pathways.Has excellent communication and stakeholder engagement skillsCan work effectively across organisational and professional boundaries.Is committed to improving patient outcomes and reducing health inequalities.
About us
Why join us?
Be part of a forward-thinking PCN delivering innovative, proactive care models.Work within a supportive, collaborative neighbourhood team.Play a key role in shaping integrated care services locally.Opportunity to make a real difference to patients with complex needs.
Job description Job responsibilities
Role Purpose
The MDT Coordination, Clinical Care Coordination and Integrated Care Manager will support South One PCN to deliver high quality, proactive, and integrated care for patients with long-term conditions (LTCs).
The postholder will:
Coordinate and optimise Multi-Disciplinary Team (MDT) workingProvide clinical care coordination across pathwaysThe role ensures effective delivery of the LTC Proactive Care and Quality and Outcomes Framework (QOF) through jointed-up, person-centred, and data-informed care, improving outcomes and reducing health inequalities.
Key Duties and Responsibilities (LTC Proactive Care QOF Aligned)
MDT Coordination and Delivery
Coordinate and support regular, structured MDT meetings for South One PCN, ensuring alignment with LTC Proactive Care QOF requirements.Organise MDTs at practice, neighbourhood, PCN, RPN or Borough levels as locally determined.Ensure MDT meetings are focused on high-need patients and result in clear actions, ownership, and follow-up.Maintain consistent MDT processes, agendas, case selection, documentation, and tracking outcomes.Clinical Care Coordination
Coordinate care for patients discussed within MDTs, ensuring timely follow-up of agreed actions and interventions.Act as a central point of coordination between primary care community services, social care, and voluntary sector partners.Support navigation of patients through complex care pathways, improving continuity and reducing fragmentation of care.Ensure personalised care plans or implemented, reviewed, and updated in collaboration with MDT members.Identify gaps in care and escalate concerns appropriately to clinical leads.Supports proactive management of patients at risk of deterioration, admission, or poor outcomes.Identification and Proactive Management of LTC Patients
Support identification and prioritisation of patients with multiple LTCs, frailty, or high risk.Ensure MDT discussions focus on high-risk and complex cohorts in line with QOF indicators.Facilitate development and review of proactive, personalised care plansPerson-Centred and Integrated Care
Enable MDTs to deliver holistic, person-centred care planning covering physical, mental, and social needs.Promote shared decision making and continuity of care.Ensure MDT actions translate into coordinated and effective care delivery across South One PCN.Effective MDT Working and Professional Collaboration
Facilitate collaboration between primary care, community services, social care, and voluntary sector organisations.Ensure appropriate professional representation within MDTs .Promote Integrated ways of working to reduce duplication and improve patient experience.Health Inequalities and Targeted Support
Ensure MDT And care coordination activity targets patients with health inequalities or barriers to access.Support production of on warranted variation across the South one PCN population.Align work with prevention, early intervention, and neighbourhood priorities.Quality, Outcomes and Continuous Improvement
Monitor MDT activity and care coordination effectively against LTC proactive care quote indicators.Support collection of evidence demonstrating improvement in patient outcomes and service delivery.Use data, feedback column and learning to drive continuous improvement.Governance, Reporting and Assurance
Support delivery assurance for the LTC Proactive Care QOF within South One PCN.Provide reporting to PCN leadership, RPN, and ICB.Act as a key point of contact for MDT and care coordination-related performance matters.
Person Specification
Qualifications Essential
Educated to degree level or equivalent experience in relevant field (e.g. healthcare management, public health, nursing, allied health professional, or social care) Evidence of continuous professional development relevant to integrated care, care coordination, or service delivery Strong working knowledge of NHS systems, primary care, or community care environments
Desirable
Professional modification in a health or social care discipline (e.g. nursing, AHP, social work) Training or certification and quality improvement methodologies (e.g QI, PD SA, Lean) knowledge or training related to long-term condition management, population health, or integrated care Understanding of LTC Proactive Care or similar NHS frameworks
Experience Essential
Experience working in a PCN setting. Knowledge of LTC Proactive Care QOF or similar frameworks. Experience in quality improvement methodologies. Understanding of population health approaches.
Desirable
Effective and DTS delivering proactive, coordinated care. Strong clinical care coordination improvement patient pathways and experience. Improved outcomes for patients with long term conditions. Reduction in health inequalities across the PCN population.
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 Star Lane Medical Centre
Address South One PCN
121 Star Lane
Canning Town
Newham
E16 4QH
United Kingdom
Employer's website https://www.starlanemedicalcentre.nhs.uk (Opens in a new tab)