Job Description

This is an exciting and developing role which involves working closely with the PCN and the wider multidisciplinary team. The role will be pivotal in helping to deliver the best possible outcomes for patients.
Care Coordinators will support member practices in coordinating key activity including access to services, advice, and information, and ensuring health and care planning is proactive, supportive, holistic and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care and the wider health and care system.
You will need outstanding people skills, a caring nature and good IT skills with a desire to learn in this ever-changing environment
An ethos of promotion of independence, shared decision making, personalisation and partnership-working is integral to this role.
Interviews planned to take place w/c 9th June 2025
Main duties of the job
Essential attributes for the role
Excellent communication and interpersonal skills
Good teamworking skills
Self-motivated and able to work on own
Good organisational skills
About us
Two Harbours Healthcare is a not for profit organisation led by local General Practices in Weymouth and Portland. Our goal is to work more closely together (and with stakeholders) to share expertise, resources and provide services for the NHS.
Date posted
24 April 2025
Pay scheme
Other
Salary
xc2xa313.31 to xc2xa313.97 an hour
Contract
Permanent
Working pattern
Full-time, Part-time
Reference number
B0205-25-0007
Job locations
Lynch Lane Offices
Lynch Lane
Weymouth
Dorset
DT4 9DN
Job description
Job responsibilities

• Work with individual practice teams and primary care professionals within the PCN to identify and manage a caseload of patients
• Work closely and in partnership with PCN colleagues including Social Prescribing Link Workers, Health Coaches and Clinical Pharmacist(s).
• Signpost team members, patients and carers to relevant services as appropriate

• Central co-ordination role around proactive support and care planning for agreed patient cohorts
• Support patient independence, promote healthcare and well-being
• Supporting patients and carers to utilise decision aids
• Empower patients, this may include the use of validated PAM tools

• Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support
• Use healthcare technologies to optimise service delivery, access, and continuity of care for patients and carers

• Use Population Health Intelligence and Risk Stratification tools proactively to identify groups of patients for MDT discussions
• May attend and present at MDT meetings
• May support in the setting up and administration of Group Consultations

• Opportunity to develop and shape this service
• Perform any duty specifically delegated by your line manager as being properly the responsibility of this post.

The tasks and responsibilities in this job description may change in the light of developments within the surgery or practice and are subject to review. Job description
Job responsibilities

• Work with individual practice teams and primary care professionals within the PCN to identify and manage a caseload of patients
• Work closely and in partnership with PCN colleagues including Social Prescribing Link Workers, Health Coaches and Clinical Pharmacist(s).
• Signpost team members, patients and carers to relevant services as appropriate

• Central co-ordination role around proactive support and care planning for agreed patient cohorts
• Support patient independence, promote healthcare and well-being
• Supporting patients and carers to utilise decision aids
• Empower patients, this may include the use of validated PAM tools

• Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support
• Use healthcare technologies to optimise service delivery, access, and continuity of care for patients and carers

• Use Population Health Intelligence and Risk Stratification tools proactively to identify groups of patients for MDT discussions
• May attend and present at MDT meetings
• May support in the setting up and administration of Group Consultations

• Opportunity to develop and shape this service
• Perform any duty specifically delegated by your line manager as being properly the responsibility of this post.

The tasks and responsibilities in this job description may change in the light of developments within the surgery or practice and are subject to review.
Person Specification
Experience
Essential

• Data analysis and interpretation
• Experience of working with patients or the public in a customer care environment

Desirable

• Primary Care experience
• Working in a healthcare setting as part of a team

Qualifications
Essential

• Good general secondary education including Maths and English

Desirable

• Presentation skills
• Change management

Knowledge
Essential

• Good working knowledge of primary care and the challenges facing patient care in the NHS
• A good range of IT knowledge including Word, Excel, email and databases

Desirable

• IT GP clinical system, SystmOne
• Needs of patients with long-term conditions
• Health promotion strategies and Public Health issues in the local area
• Change-management and ability to support patients to change lifestyle
• Negotiation and conflict management skills
• Ability to identify determinants on health in the local area
• Awareness of local and national health policy
• Awareness of issues within the wider health econo

Skills
Essential

• Understanding and adherence to strict confidentiality
• Excellent communication and interpersonal skills, both written and verbal
• Good teamworking skills
• Able to analyse & extract relevant information
• Good organizational skills
• Able to use own judgement, resourcefulness and common sense
• Able to work under pressure
• Able to prioritise workload and meet deadlines

Personal Qualities
Essential

• Self-directed working using initiative
• Innovative approach
• Highly motivated
• Caring, compassionate and confident
• Calm approach, performing under pressure
• Positive attitude
• Pleasant and articulate

Person Specification
Experience
Essential

• Data analysis and interpretation
• Experience of working with patients or the public in a customer care environment

Desirable

• Primary Care experience
• Working in a healthcare setting as part of a team

Qualifications
Essential

• Good general secondary education including Maths and English

Desirable

• Presentation skills
• Change management

Knowledge
Essential

• Good working knowledge of primary care and the challenges facing patient care in the NHS
• A good range of IT knowledge including Word, Excel, email and databases

Desirable

• IT GP clinical system, SystmOne
• Needs of patients with long-term conditions
• Health promotion strategies and Public Health issues in the local area
• Change-management and ability to support patients to change lifestyle
• Negotiation and conflict management skills
• Ability to identify determinants on health in the local area
• Awareness of local and national health policy
• Awareness of issues within the wider health econo

Skills
Essential

• Understanding and adherence to strict confidentiality
• Excellent communication and interpersonal skills, both written and verbal
• Good teamworking skills
• Able to analyse & extract relevant information
• Good organizational skills
• Able to use own judgement, resourcefulness and common sense
• Able to work under pressure
• Able to prioritise workload and meet deadlines

Personal Qualities
Essential

• Self-directed working using initiative
• Innovative approach
• Highly motivated
• Caring, compassionate and confident
• Calm approach, performing under pressure
• Positive attitude
• Pleasant and articulate