PCN Care Coordinator - New Hall Surgery

The role is both the delivery of evidence-based practice for patients presenting with a chronic condition, and the provision of preventative health care to the practice population. for the care delivered to their patients, demonstrating critical thinking and skills in clinical decision-making in the management of patients.

The role is not a regular 9am-5pm job; the job requires innovation, flexibility and commitment and the postholder will be required to work resourcefully as part of the team to ensure tasks are completed., We are one of the largest GP super-partnerships in the UK, serving over 450,000 patients and with a workforce of 1500+. We are unique, we are always looking at ways to improve our delivery of services through the implementation of new and innovative solutions that we can scale across the organisation. Your job is to work directly with key stakeholders to help us to harmonise ways of working and improve working practices to improve patient and staff satisfaction. Most management roles focus on personnel management / project management. This is a role that will equip you with a portfolio of nursing in primary care with career advancing opportunities., Please refer to the supporting documents section to retrieve the JD detailing the core responsibilities of this role.

• Triaging referrals and allocating to appropriate clinician/service


• Post discharge follow up phone calls.


• Administrative duties including onward referrals and liaising with ICS services.


• Face to face Reviews and Following up on referrals.


• Coordinating care home monthly MDT (agenda, invites, minutes, follow ups)


• Co ordinating weekly MDT.


• Managing the watch list caseload of patient within the community/palliative patients


• Developing a directory of contact numbers for services


• Care navigation.


• Audit


• Take overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) ward round) and the smooth running of integrated care within the team setting. A key role of the Care Coordinator will be to schedule the weekly MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.


• Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.


• 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.


• Work with the PCN multi-disciplinary team to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
  
  Minimum of 2 years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field


Experience of working in a multi-disciplinary setting where influence and negotiation is required.

Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.

Experience providing advice/signposting to users.

Experience - Desirable

Experience of undertaking quality improvement activity

Experience of using technology and digital tools to support health and wellbeing.

Experience of coproduction with patients or service-users

Knowledge - Essential

Level 2 qualification in Maths and English

Understanding of health and social care processes

Knowledge and familiarity with medical terminology

Understanding of social determinants of health and how these can be addressed with patients.

High levels of health literacy

Excellent knowledge of Microsoft Office

Knowledge - Desirable

Educated to level 3 in a relevant topic, or working towards

Knowledge of a range of technology and digital tools that can be used support health and wellbeing.

Understanding of current issues facing the NHS

Sound understanding of disease prevention primary, secondary and tertiary and how patients can build prevention into their lifestyle.

Awareness of local services and resources for individuals, carers and families

Skills - Essential

Skilled in use of person-centred measurement & outcomes delivery

Able to collate and disseminate voluminous and sometimes complex information.

Able to assess and work within an individual's level of health literacy and support them to increase their understanding.

Proven record of excellent written and verbal communication skills

Excellent motivational and influencing skills.

Excellent interpersonal skills

Able to deal with service users sensitively.

Able to work as part of a team.

Able to prioritise and manage own workload.

Strong analytical and judgement skills

Ability to analyse and interpret information and present results in a clear and concise manner Excellent organisational and administration skills.

Skills - Desirable

Able to use asset-based approaches when working with individuals and families.

Able to use patient activation tools to measure knowledge, skills, and confidence in managing their own health and wellbeing.

Able to use NHS Choices website effectively.

Personal Qualities

Professional approach to work

Good telephone manner

Strong team player

Smart appearance

Exercises tact and discretion at all times

Demonstrates initiative to handle any unforeseen events during a shift

Demonstrates flexibility towards new working practices and towards working hours

Modality Partnership Hull Division has a full-time vacancy for a Care Coordinator. The postholder will be a high performing employee who will work as part of a multi-disciplinary team across Hull Division and PCN. We are seeking dedicated postholders to join our team and who can display our CARE values: Commitment, Accountability, Respect and Excellence.

This job is suitable for individuals who have a passion for working in health care, making a real difference providing seamless patient care, and who are committed to make real changes to the health care services provided within Primary Care to improve patient care.

As an employee with us you can benefit from:

Enrolment to the NHS pension scheme

Annual leave minimum 27 days, plus 8 days bank holiday pro rata

Employee discounts and benefits scheme

Employee assistance programme (EAP)

Education and career pathways

Family friendly policies

Flexible working

Wellbeing support

If you are interested in learning more, please read on.