Job Description

Job Overview

We are seeking an enthusiastic and organised Care Coordinators to join the growing multi-disciplinary team within the North Wilts Border PCN. Building on our successful care coordination model, this role is key to delivering personalised, joined-up care for our patients.

As a Care Coordinator, you will work closely with PCN practices and a wide range of health professionals, including GPs, nurses, paramedics, pharmacists, and others. You will be responsible for coordinating access to services, information, and support ensuring that care is timely, efficient, and centred around the needs of each patient.

This is a vital role that contributes directly to:

Enhancing patient experience and outcomes Preventing avoidable hospital admissions Supporting the NHS Long Term Plan and PCN priorities through integrated, person-centred care You will act as a key point of contact, helping to bridge the gap between patients and clinical teams. Your work will help free up valuable clinical time while ensuring that patients feel informed, supported, and confident in managing their own health and wellbeing.

Primary Responsibilities

Develop and maintain a comprehensive directory of local services, including charities, community and voluntary sector organisations, and relevant private providers, ensuring up-to-date information is available for staff and service users. Deliver dedicated support to unpaid carers through carer clinics, offering guidance, signposting, emotional support, and assistance in accessing appropriate services or respite options. Coordinate safe and effective hospital discharge processes for patients under and over 75, ensuring timely follow-up care, medication reviews, and clear communication with families and community services. Manage referrals to Adult Social Care, liaising closely with social workers to ensure individuals receive timely assessments and appropriate care packages that meet their needs. Work collaboratively with community health teams, including District Nurses, Occupational Therapists, and Physiotherapists, to support holistic care planning and facilitate referrals for clinical or functional support. Engage Adult Social Care when issues of safeguarding or the need for a care assessment arise, ensuring concerns are escalated appropriately Build strong working relationships with care homes and teams supporting housebound patients to promote resident wellbeing, coordinate vaccinations, arrange social prescribing visits, and ensure effective communication between all involved providers. Arrange wheelchair assessments and referrals and support individuals in accessing appropriate mobility equipment and adaptations. Conduct and coordinate Dementia Reviews, including running assessment clinics, supporting carers, gathering input from GPs and community services, and ensuring follow-up actions are completed. Deliver NHS Health Check clinics, overseeing the full process from assessment to coordination of results, referrals, and lifestyle interventions to ensure effective follow-through for patients. Manage, monitor, and allocate LWT responsibilities across the team, ensuring timely completion, consistent documentation, and effective workflow coordination.

Secondary Responsibilities

Work alongside practice teams to streamline care for patients with complex or long-term needs, aiming to smooth their journey through the system and accelerate access to appropriate support. Use agreed clinical criteria and population health management tools to flag individuals who would benefit from coordinated care, ensuring proactive rather than reactive support. Respond to patient queries and provide clear, accessible information that helps them understand and manage their health and care plans. Arrange patient appointments as needed and promote vaccination uptake among eligible groups to support prevention and early intervention. Tailor support to each person's priorities, ensuring care is sensitive to cultural background, personal values, disabilities and long-term conditions Coordinate transitions between different parts of the health and care system, ensuring referrals are timely and that patients move smoothly between services without gaps in support. Hold a defined caseload and act as a consistent point of contact for patients across primary care, community services, secondary care and care home environments Oversee referrals to clinical and non-clinical services, maintaining effective communication with internal healthcare teams and wider partner organisations. Provide calm, practical support to people who feel overwhelmed or uncertain about navigating the care system, helping them build confidence and reduce distress. Address health inequalities through focused work with priority groups, including people with multiple health needs or those at higher risk of poor outcomes.

Qualification

Essential

Good standard of education with 5 GCSE's or equivalent. NVQ Level 3 in Health & Social Care Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint and Outlook). Commitment to continuing professional development, including the Personalised Care Institute Course(s).
Desirable

Qualified in Phlebotomy Blood pressure taking Experience with vital observations

Skills

Communication

Excellent interpersonal and communication skills. Ability and confidence to handle difficult conversations. Ability to structure conversations using a coaching approach based on what matters to the person. Be able to talk to a wide range of professionals appropriately. Ability to nurture key relationships and maintain networks.
Attitude & Behaviour

Displays care, compassion, sensitivity and responsiveness to other peoples feelings and needs Able to work as part of a team, co-operating to work together and in conjunction with others and willing to help and assist wherever possible and appropriate appreciating the value of diversity in the workplace Able to develop, establish and maintain positive relationships with others both internal and external to the organisation and with patients and their carers Able to work under pressure, dealing with peaks and troughs in workload. Highly motivated and reliable Demonstrates values consistent with those of North Wilts Border PCN
Desirable

Positive and flexible attitude to dealing with change; able to respond to the changing needs of the patient in an appropriate and timely manner; willing to change and accept change and to explore new ways of doing things and approaches Has a strong degree of personal integrity; able to adhere to standards of conduct based on a culture of equality and fairness Be able to manage multiple demands and prioritise appropriately. Ability to seek solutions and solve problems using your own initiative. Adaptability, flexibility and the ability to cope with uncertainty and change. Be able to focus in a busy work environment. Demonstrate a strong desire to improve performance and make a difference by focusing on goals. Work confidentially and maintain the trust of colleagues and patients. Excellent time keeping.
Job Type: Full-time

Pay: 13.50-14.50 per hour

Expected hours: 37.5 per week

Benefits:

Bereavement leave Company events Company pension Health & wellbeing programme On-site parking Sick pay Store discount
Work Location: In person

Application deadline: 01/06/2026