North Wilts Border PCN Ltd Company

PCN Care Coodinator (A)

The closing date is 05 October 2025

Job summary

We are seeking an enthusiastic and organised Care Coordinators to join the growing multi-disciplinary team within the North Wilts Border Primary Care Network (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 supportensuring 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.

Main duties of the job

Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan.
Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through the use of the Patient Activation Measure
Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals
Support the coordination, administration and delivery of MDTs within the PCN and to work as a key member of the MDT to help support the development of effective MDT meetings.
Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN.

About us

North Wilts Border PCN is a collaborative NHS partnership made up of six GP surgeries, working together to deliver high-quality, patient-centred care to over 54,000 people across our local communities. We are proud to be rooted in our community and are committed to staying connected with and supporting the people we serve.

In addition to our dedication to clinical excellence, we are also a teaching and training network, supporting medical students from the University of Bath and GP trainees from across the South West region.

Our diverse multidisciplinary team includes Specialist Practitioners, Health & Wellbeing Coaches, Care Coordinators, and Clinical Directors. We place great value on the contributions of our Living Well team and are committed to supporting the personal and professional development of all staff.

What We Offer:

A supportive and inclusive team culture that is well-led
Opportunities for professional development and leadership
Flexible working arrangements
Access to mentorship and clinical supervision
Involvement in innovative projects and service development
Employee Assistant programme
NHS Pension
Cost coverage of an Enhanced DBS
Excellent Induction
25 days annual leave pro rata

Date posted

06 September 2025

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time

Reference number

W0050-25-0005

Job locations

Tinkers Lane Surgery

Tinkers Field

Royal Wootton Bassett

Swindon

Wiltshire

SN4 7AT

Doctors Surgery

Willis Way

Purton

Swindon

SN5 4BD

The Surgery

113 High Street

Cricklade

Swindon

SN6 6AE

New Court Surgery

Borough Fields Shopping Centre

Royal Wootton Bassett

Swindon

Wiltshire

SN4 7AX

Malmesbury Primary Care Centre

Priory Way

Malmesbury

Wiltshire

SN16 0FB

The Tolsey Surgery

High Street

Sherston

Malmesbury

Wiltshire

SN160LQ

Job description

Job responsibilities

PRIMARY RESPONSIBILITIES

a) Work with practice teams to coordinate care for patients with more complex or ongoing needs, improving the patient journey and expediting care where necessary.

b) Proactively identify patients requiring care coordination using agreed criteria, population health management tools, and clinical input.

c) Support patients in accessing benefits, training, and employment opportunities where appropriate.

d) Help patients manage their health by responding to queries and ensuring access to clear, quality information about their care.

e) Coordinate appointments and encourage the uptake of vaccinations among eligible groups.

f) Focus on what matters most to each individual patient, ensuring support is personalised and culturally sensitive, especially for people from diverse backgrounds and those living with disabilities or long-term conditions.

g) Navigate and coordinate care across health and care systemsensuring timely, appropriate referrals and seamless transitions between services.

h) Manage a caseload of patients, acting as their single point of contact across primary care, community care, secondary care, and care home settings.

i) Facilitate and monitor referrals to both clinical and non-clinical services, working closely with healthcare teams and external partners.

j) Empower and enable patients to manage their own care and take an active role in their health and wellbeing.

k) Support people who may be anxious, confused, or overwhelmed by the care system, helping reduce stress and build confidence.

l) Liaise with Adult Social Care when required to raise safeguarding concerns or request care assessments.

m) Tackle health inequalities through targeted work with identified population groups, such as those with long-term conditions or multiple health needs.

N) Uphold all relevant policies and procedures, including safeguarding, confidentiality, lone working, information governance, health and safety, and equality, diversity andinclusion.

SECONDARY RESONSIBILITIES

In addition to the primary responsibilities, the Care Coordinator may be requested to:

a. Support the PCN audit programme & undertaking audits when necessary

b. Support junior members of the team, providing guidance when necessary

c. Participate in local initiatives to enhance service delivery and patient care

d. Support and participate in shared learning across the practice

e. Participate in PCN projects as directed by PCN manager

f. Take personal responsibility for own learning and development, including the requirement to maintain competency, achieving all targets set in own Personal Development Plan (PDP)