Care Coordinator

Job description

Job responsibilities

Patient Coordination & Support

Act as a key contact for patients living with frailty and their carers.

Support patients to navigate appointments, care plans, and community services.

Proactively organise and follow up on frailty assessments and wellbeing checks.

Schedule and coordinate regular reviews, home visits, and clinician appointments.

Work closely with care homes and people in the community.

Multidisciplinary Team (MDT) Administration

Prepare patient lists, agendas, and documentation for MDT meetings.

Attend MDT meetings to take accurate minutes and record outcomes.

Liaise with GPs, nurses, ANPs, community teams, social prescribers, and social care.

Care Planning & Monitoring

Assist with the creation and updating of personalised care plans.

Ensure frailty coding and anticipatory care information is kept up to date.

Monitor high-risk patients and escalate any issues to the clinical team.

Communication & Liaison

Support communication between the practice, external providers, hospitals, and community services.

Assist with safe discharge planning and follow-up after hospital admissions.

Build positive relationships with patients and their families.

Administrative & Operational Support

Manage frailty team inboxes, phone calls, and incoming referrals.

Book appointments, home visits, and clinic slots for the frailty team.

Maintain accurate clinical records following GDPR and confidentiality requirements.

Support audits, data collection, and service activity reporting.

Professional Development & Extended Duties

Conduct basic patient reviews related to frailty (e.g., wellbeing checks, follow-up assessments).

Support clinicians with simple observations (e.g., BP, pulse, basic measurements).

Contribute to long-term condition reviews under protocol.

Conduct proactive outreach to frail or housebound patients.

Assist in preventative health initiatives and monitoring tasks.

Person Specification

Qualifications

Essential

• Strong organisational skills with the ability to manage multiple priorities.
• Excellent communication and interpersonal skills.
• Experience in an administrative, coordination, or care-related role.
• Confidence working with older adults and vulnerable patients.
• Ability to travel across surgery sites.
• IT literacy and willingness to learn clinical systems (SystmOne).
• GCSE grade A to C in English and Maths

Desirable

• Experience within primary care or NHS settings.
• Knowledge of frailty pathways or older peoples services.
• Experience working as part of a multidisciplinary team.
• Interest in developing clinical competencies.
• The ability to perform venepuncture is preferred, can be something to work towards.

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.

Employer details

Employer name

Fitzalan Medical Group

Address

Fitzalan Medical Group

Fitzalan Road

Littlehampton

West Sussex

BN17 5JR

Employer's website

https://www.fitzalanmedicalgroup.co.uk/ (Opens in a new tab)