Job Description

Care Coordinator (Trinity Health Group PCN)

The closing date is 23 July 2025

Job summary

Are you a compassionate, organised individual with a passion for making a real difference in peoples lives?

If so this is an exciting opportunity for the right candidate to join our dynamic team of existing Care Co-ordinators, working with the GP Surgeries that form Trinity Health Group (PCN)

Under the direction of the PCN team, the coordinator will identify a cohort of patients who meet specific criteria as determined by the Service priority areas using population health intelligence.

You will deliver personalised holistic healthcare and support in order to manage their needs proactively, exploring options or a single personalised care and support plan. Provide advice, guidance and signpost to other services, co-ordinate patient care services and work with the care team to evaluate interventions.

Main duties of the job

The Care Co-ordinator will proactively (not an exhaustive list):

Under direction, use population health intelligence to identify a cohort of patients in line with Service priority areas and contractual requirements and undertake intervention as appropriate, reporting back on progress regularly

Help patients to manage their needs through answering queries, making and managing appointments and ensuring that they have good quality written and verbal information to help them make choices about their care, using tools to understand peoples level of knowledge and confidence in managing their own health

Identify when urgent action or a step up in care is required and promptly alert the relevant professionals involved, highlighting any safety concerns

Support the patients to access self-management education courses, peer support and other interventions that support them in their health and wellbeing

Develop and maintain effective and positive relationships with multidisciplinary professionals, practice staff and other teams, facilitating a co-ordinated approach, referring and liaising with them in the best interest of the patients care

Work within the parameters of own skills and knowledge, recognising when it is necessary to bring in other expertise or ask for further guidance from peers or supervisors

Any other duties and responsibilities in keeping with the level and nature of the role.

This role will be based primarily at Trinity Health Centre, although this could change

About us

Trinity Health Group is a PCN made up of four practices on the west of the district (Trinity Medical Centre, Maybush Medical Centre, Crofton and Sharlston Medical Practice and Warrengate Medical Centre). Our vision is that all our patients should have the same chance at a happy, healthy life. We believe that a sustainable, resilient Primary Care Service working collaboratively with volunteer and community services and social enterprise organisations supports this vision. Our Mission is to add years to the lives of our patients and to add life to those years.

Job description

Job responsibilities

Under direction, use population health intelligence to identify a cohort of patients in line with Service priority areas and contractual requirements and undertake intervention as appropriate, reporting back on progress regularly; Contact Patients in order to understand their needs and support holistic and shared decision making conversations through establishing trust; Help patients to manage their needs through answering queries, making and managing appointments and ensuring that they have good quality written and verbal information to help them make choices about their care, using tools to understand people's level of knowledge and confidence in managing their own health; Navigate and signpost patients and their carers appropriately, working alongside social prescribing link workers, health and wellbeing coaches and other primary care roles; Maintain good relationships with patients which enables regular checking in to evaluate and document their progress; Identify when urgent action or a step up in care is required and promptly alert the relevant professionals involved, highlighting any safety concerns; Support the patients to access self management education courses, peer support and other interventions that support them in their health and wellbeing; Support the development of a single personalised care and support plan with patients and family members to bring together their identified care needs; Support patients to take up training and educational opportunities and to access appropriate benefits where eligible, for example through referral to social prescribing link workers; Develop and maintain a detailed knowledge of local community and voluntary sector services to enable supported signposting of people with an identified need; Support carers by identifying unpaid carers and directing them to access services as appropriate; Develop and maintain effective and positive relationships with multidisciplinary professionals, practice staff and other teams, facilitating a co-ordinated approach, referring and liaising with them in the best interest of the patients care; Attend and support the coordination and delivery of MDT meetings in relation to care homes; Assist and support in vaccination programmes as required; Refer patients to other health professionals where necessary, maintaining excellent links across all areas of the Service; Update patient documentation and computer systems as required in an accurate and timely manner; Provide patient focussed care, often acting as first point of contact for care needs; Develop excellent relationships with patients and carers in order to establish trust and encourage communication which puts the patient and their needs at the centre; Work within the parameters of own skills and knowledge, recognising when it is necessary to bring in other expertise or ask for further guidance from peers or supervisors; Work effectively as part of a multi-professional team in collaboration with other members of the service; Maintain an awareness of developments in practice; Ensure patient confidentiality at all times; Assist with the training and development of others where required; Follow all Company, PCN and Practice Policies and Procedures including those relating to confidentiality, health and safety; Attend Company, PCN, team and Practice meetings and updates as required; Access relevant networks and partnerships to share good practice, expertise and resources; Any other duties and responsibilities in keeping with the level and nature of the role.

Person Specification

Experience

Essential

Experience of working directly with the general public Experience of using computer and IT systems with a basic level of IT literacy

Desirable

Experience of using SystmOne and/or similar Experience in Primary Care, voluntary sector and/or healthcare Competent use of Microsoft 365 applications

Skills, Aptitude & KnowledgeEssential

Ability to communicate complex and sensitive information with people at all levels by telephone, email and face-to-face Ability to form a natural bond and put people at ease from all background and communities, respecting lifestyles and diversity Ability to handle pressurised and challenging situations Ability to have difficult conversations with confidence and compassion Ability to influence and persuade Compassionate, respectful and empathic with patients Aware of own abilities and know when to seek support if needed Ability to manage own time effectively, prioritise workload and work to deadlines Problem solving and interpersonal skills Ability to travel across the locality on a regular basis, including visiting people in their own homes and care homes with a full driving license and access to a car Good clinical systems IT knowledge of EMIS/SystmOne/Vision Understanding of and prepared to adhere to relevant Policies and Procedures

Desirable

Basic understanding of Primary Care environment Knowledge of the local area and patient demographics Good clinical systems IT knowledge of EMIS/SystmOne/Vision

Qualifications

Essential

Basic literacy and numeracy skills Willingness to undertake relevant training by the Personalised Care Institute Willingness to undertake up to date statutory and mandatory training as defined by

Conexus Healthcare

Desirable

Care certificate Relevant qualification from the Personalised Care Institute or similar Trained in Care Navigation or similar Ability to speak a language relevant to the patient demographic
Job Type: Permanent

Pay: 24,477.00 per year

Work Location: In person

Reference ID: A0430-25-0033