Job summary
The Care Coordinator / Care Navigator will support the delivery of proactive, person-centred care within the GP practice.
The post holder will:
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Coordinate care for patients with complex needs, long-term conditions, frailty, or high service use.
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Act as the first point of contact for patients, signposting and navigating them to the most appropriate service.
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Support the multidisciplinary team (MDT) in delivering joined-up, safe, and effective care.
The role aims to improve patient outcomes, enhance patient experience, reduce health inequalities, and ensure patients receive the right care, at the right time, in the right place.
Main duties of the job
Act as the first point of contact for patients, face-to-face or by phone, providing front-line support and guidance. Signpost patients to appropriate services including GP, nurse, pharmacist, social prescriber, and community or voluntary services, following care navigation protocols to ensure safe and effective care. Support patients to use online consultations and digital services, and escalate urgent or emergency cases appropriately.
Coordinate care for patients who would benefit from personalised support, using risk stratification tools and clinical searches. Assist in developing, implementing, and reviewing care plans, ensuring accurate recording on clinical systems (e.g., EMIS). Support patients to understand their conditions, promote self-management, and coordinate appointments, follow-ups, and referrals across primary, secondary, and community care.
Maintain accurate patient records, run clinical system searches to identify target cohorts, support recalls for long-term conditions and enhanced services, and assist with data collection for QOF, Enhanced Services, and other contractual requirements.
About us
We are a single GP partnerled practice based in Wandsworth, serving our local community with dedication and compassion.
Our team includes 1 GP Partner Lead, 5 sessional GPs, 2 clinical pharmacists, 2 practice nurses, 1 healthcare assistant, an Operations Manager, a care coordinator, and a receptionist/administrator. As a small practice, we work closely together, with every team member playing an important role in delivering safe, high-quality care. We are a friendly, supportive and genuinely happy team that values mutual respect, open communication, and shared learning.
We strive to provide the best possible care to our patients. We believe everyone should have access to individualised, evidence-based and holistic healthcare. Patient-centred empowerment is central to our ethos: we support patients to understand their conditions, treatment options and health goals, enabling them to make informed decisions and take an active role in their care.
Working with us means being part of a collaborative environment where your contribution is valued, your development is supported and patient care always comes first.
Job description
Job responsibilities
Job Description
Job Title
Care Coordinator / Care Navigator
Responsible to
Operations Manager
Accountable to
GP Partner
Base
GP Practice
Job Purpose
The Care Coordinator / Care Navigator will provide proactive, person-centred support to patients within the GP practice and/or Primary Care Network. The post holder will coordinate care for patients with complex or long-term conditions, frailty, or high service use, and act as a first point of contact to navigate patients safely and efficiently through health, social care, and community services.
The role aims to improve patient outcomes, enhance patient experience, reduce health inequalities, and ensure patients receive the right care, in the right place, at the right time.
Key Duties and Responsibilities
1. Care Coordination
- Identify patients who may benefit from care coordination using risk stratification tools and clinical system searches.
- Develop, implement, and review personalised care plans in collaboration with GPs, nurses, and MDT members.
- Support patients to understand their care plans, manage their conditions, and access relevant services.
- Monitor patient progress, escalate concerns, and ensure timely follow-up.
- Assist in meeting contractual requirements, including QOF, Enhanced Services, and annual reviews.
2. Care Navigation
- Act as the first point of contact for patients seeking advice, guidance, or support.
- Signpost patients to the most appropriate internal and external services, including social prescribing, mental health, voluntary sector, and community support.
- Provide clear and timely information to patients about available services and pathways.
- Triaging patient enquiries, recognising urgent or complex cases, and escalating appropriately.
- Support patients in accessing online consultation systems, digital services, and self-management resources.
4. Administrative & Data Responsibilities
- Maintain accurate, contemporaneous patient records on clinical systems such as EMIS or SystmOne.
- Run searches to identify target patient groups, track progress, and generate reports for clinical and management teams.
- Support recall systems for long-term condition reviews and enhanced services.
- Assist in audits, quality improvement initiatives, and data collection for service monitoring.
5. Safeguarding and Governance
- Recognise and escalate safeguarding concerns in line with practice policy.
- Maintain confidentiality in accordance with GDPR and NHS Information Governance standards.
- Participate in clinical governance, quality improvement, and service development initiatives.
- Complete mandatory training and maintain awareness of best practice guidance.
Job description
Job responsibilities
Job Description
Job Title
Care Coordinator / Care Navigator
Responsible to
Operations Manager
Accountable to
GP Partner
Base
GP Practice
Job Purpose
The Care Coordinator / Care Navigator will provide proactive, person-centred support to patients within the GP practice and/or Primary Care Network. The post holder will coordinate care for patients with complex or long-term conditions, frailty, or high service use, and act as a first point of contact to navigate patients safely and efficiently through health, social care, and community services.
The role aims to improve patient outcomes, enhance patient experience, reduce health inequalities, and ensure patients receive the right care, in the right place, at the right time.
Key Duties and Responsibilities
1. Care Coordination
- Identify patients who may benefit from care coordination using risk stratification tools and clinical system searches.
- Develop, implement, and review personalised care plans in collaboration with GPs, nurses, and MDT members.
- Support patients to understand their care plans, manage their conditions, and access relevant services.
- Monitor patient progress, escalate concerns, and ensure timely follow-up.
- Assist in meeting contractual requirements, including QOF, Enhanced Services, and annual reviews.
2. Care Navigation
- Act as the first point of contact for patients seeking advice, guidance, or support.
- Signpost patients to the most appropriate internal and external services, including social prescribing, mental health, voluntary sector, and community support.
- Provide clear and timely information to patients about available services and pathways.
- Triaging patient enquiries, recognising urgent or complex cases, and escalating appropriately.
- Support patients in accessing online consultation systems, digital services, and self-management resources.
4. Administrative & Data Responsibilities
- Maintain accurate, contemporaneous patient records on clinical systems such as EMIS or SystmOne.
- Run searches to identify target patient groups, track progress, and generate reports for clinical and management teams.
- Support recall systems for long-term condition reviews and enhanced services.
- Assist in audits, quality improvement initiatives, and data collection for service monitoring.
5. Safeguarding and Governance
- Recognise and escalate safeguarding concerns in line with practice policy.
- Maintain confidentiality in accordance with GDPR and NHS Information Governance standards.
- Participate in clinical governance, quality improvement, and service development initiatives.
- Complete mandatory training and maintain awareness of best practice guidance.
Person Specification
Qualifications
Essential
- GCSEs (or equivalent), including English and Maths
- Evidence of continuous professional development.
Desirable
- NVQ Level 3 in Health & Social Care or equivalent experience,
- Care Navigation or Health Coaching training,
Knowledge & Skills
Essential
- Experience using total triage models to support patient access and prioritisation.
- Knowledge of or equivalent digital healthcare communication tools
- Understanding of confidentiality, data protection, and safeguarding,
- Knowledge of long-term conditions and proactive care approaches,
- Excellent communication and interpersonal skills,
- Ability to prioritise workload and manage competing demands,
- Strong organisational and time-management skills,
- Ability to work independently and as part of a multidisciplinary team,
- IT proficient, with experience in clinical systems and office software,
Desirable
- Ability to support behaviour change and self-management,
- Experience in care planning and pathway development,
- Problem-solving skills and a proactive approach to service improvement,
Experience
Essential
- At least 2 years of experience in a GP practice, Primary Care Network, or community care setting,
- Experience managing sensitive or confidential information,
- Experience in administrative work and record-keeping,
Desirable
- Experience working in healthcare, social care, or customer-facing environments,
- Experience using EMIS, SystmOne, or similar clinical systems,
- Experience supporting patients with complex needs or long-term conditions,
Person Specification
Qualifications
Essential
- GCSEs (or equivalent), including English and Maths
- Evidence of continuous professional development.
Desirable
- NVQ Level 3 in Health & Social Care or equivalent experience,
- Care Navigation or Health Coaching training,
Knowledge & Skills
Essential
- Experience using total triage models to support patient access and prioritisation.
- Knowledge of or equivalent digital healthcare communication tools
- Understanding of confidentiality, data protection, and safeguarding,
- Knowledge of long-term conditions and proactive care approaches,
- Excellent communication and interpersonal skills,
- Ability to prioritise workload and manage competing demands,
- Strong organisational and time-management skills,
- Ability to work independently and as part of a multidisciplinary team,
- IT proficient, with experience in clinical systems and office software,
Desirable
- Ability to support behaviour change and self-management,
- Experience in care planning and pathway development,
- Problem-solving skills and a proactive approach to service improvement,
Experience
Essential
- At least 2 years of experience in a GP practice, Primary Care Network, or community care setting,
- Experience managing sensitive or confidential information,
- Experience in administrative work and record-keeping,
Desirable
- Experience working in healthcare, social care, or customer-facing environments,
- Experience using EMIS, SystmOne, or similar clinical systems,
- Experience supporting patients with complex needs or long-term conditions,
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.