Job summary
We are seeking an enthusiastic and organised Care Coordinators
to join the growing multi-disciplinary team within the North Wilts Border 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 support ensuring 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
- As a Care Coordinator within the Primary Care Network (PCN), you will play a pivotal role in supporting patients to manage their health and wellbeing.
- You will use population health intelligence to proactively identify patient cohorts and develop personalised care and support plans that address their holistic needs.
- You will work closely with GPs, multidisciplinary team (MDT) members, social prescribing link workers, health and wellbeing coaches, and community services to ensure coordinated and seamless care.
You will support patients and their carers in navigating the health and social care system, answering queries, arranging and managing appointments, and providing clear verbal and written information to help them make informed choices.
Additionally, you will coordinate hospital discharges, manage referrals to adult social care, and work collaboratively with community health teams, care homes, and other providers to ensure timely and effective care.
You will also support the administration and delivery of MDT meetings, monitor and allocate team responsibilities, and maintain an up-to-date directory of local services, charities, and voluntary sector organisations to optimise patient support.
You will promote patient activation by linking individuals to self-management education, peer support, and interventions that enhance their knowledge, skills, and confidence in managing their health.
About us
North
Wilts Border PCN is a vibrant, forward-thinking Primary Care Network serving
over 56,000 patients across North Wiltshire and the borders of Swindon. Our
network brings together six GP practices
- Malmesbury Primary Care Centre,
- New Court Surgery,
- Purton Surgery,
- Cricklade Surgery,
- The Tolsey Surgery, and
- Tinkers Lane Surgery
To
deliver integrated, patient-centred care. By working together, we provide more
coordinated, accessible, and flexible services that go beyond traditional GP
appointments.
Our
multidisciplinary team consisting of GPs, paramedics, clinical pharmacists,
care coordinators, and social prescribing link workers.
Together,
we support patients medical, social, and wellbeing needs, ensuring holistic
care across our network.
This
is your chance to join a collaborative environment where innovation, teamwork,
and patient care come first.
NOTE:
Right to Work in the UK
Please
note that we are unable to offer visa sponsorship for this role. Applicants
MUST already have the right to work in the UK in order to be considered
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
Job description
Job responsibilities
Primary Responsibilities
- Develop and maintain a comprehensive directory of local services, including charities, community and voluntary sector organisations, and relevant private providers, ensuring up-to-date information is available for staff and service users.
- Deliver dedicated support to unpaid carers through carer clinics, offering guidance, signposting, emotional support, and assistance in accessing appropriate services or respite options.
- Coordinate safe and effective hospital discharge processes for patients under and over 75, ensuring timely follow-up care, medication reviews, and clear communication with families and community services.
- Manage referrals to Adult Social Care, liaising closely with social workers to ensure individuals receive timely assessments and appropriate care packages that meet their needs.
- Work collaboratively with community health teams, including District Nurses, Occupational Therapists, and Physiotherapists, to support holistic care planning and facilitate referrals for clinical or functional support.
- Engage Adult Social Care when issues of safeguarding or the need for a care assessment arise, ensuring concerns are escalated appropriately
- Build strong working relationships with care homes and teams supporting housebound patients to promote resident wellbeing, coordinate vaccinations, arrange social prescribing visits, and ensure effective communication between all involved providers.
- Arrange wheelchair assessments and referrals and support individuals in accessing appropriate mobility equipment and adaptations.
- Conduct and coordinate Dementia Reviews, including running assessment clinics, supporting carers, gathering input from GPs and community services, and ensuring follow-up actions are completed.
- Deliver NHS Health Check clinics, overseeing the full process from assessment to coordination of results, referrals, and lifestyle interventions to ensure effective follow-through for patients.
- Manage, monitor, and allocate LWT responsibilities across the team, ensuring timely completion, consistent documentation, and effective workflow coordination.
Secondary Responsibilities
- Work alongside practice teams to streamline care for patients with complex or long-term needs, aiming to smooth their journey through the system and accelerate access to appropriate support.
- Use agreed clinical criteria and population health management tools to flag individuals who would benefit from coordinated care, ensuring proactive rather than reactive support.
- Respond to patient queries and provide clear, accessible information that helps them understand and manage their health and care plans.
- Arrange patient appointments as needed and promote vaccination uptake among eligible groups to support prevention and early intervention.
- Tailor support to each person's priorities, ensuring care is sensitive to cultural background, personal values, disabilities and long-term conditions
- Coordinate transitions between different parts of the health and care system, ensuring referrals are timely and that patients move smoothly between services without gaps in support.
- Hold a defined caseload and act as a consistent point of contact for patients across primary care, community services, secondary care and care home environments
- Oversee referrals to clinical and non-clinical services, maintaining effective communication with internal healthcare teams and wider partner organisations.
- Provide calm, practical support to people who feel overwhelmed or uncertain about navigating the care system, helping them build confidence and reduce distress.
- Address health inequalities through focused work with priority groups, including people with multiple health needs or those at higher risk of poor outcomes.
Job description
Job responsibilities
Primary Responsibilities
- Develop and maintain a comprehensive directory of local services, including charities, community and voluntary sector organisations, and relevant private providers, ensuring up-to-date information is available for staff and service users.
- Deliver dedicated support to unpaid carers through carer clinics, offering guidance, signposting, emotional support, and assistance in accessing appropriate services or respite options.
- Coordinate safe and effective hospital discharge processes for patients under and over 75, ensuring timely follow-up care, medication reviews, and clear communication with families and community services.
- Manage referrals to Adult Social Care, liaising closely with social workers to ensure individuals receive timely assessments and appropriate care packages that meet their needs.
- Work collaboratively with community health teams, including District Nurses, Occupational Therapists, and Physiotherapists, to support holistic care planning and facilitate referrals for clinical or functional support.
- Engage Adult Social Care when issues of safeguarding or the need for a care assessment arise, ensuring concerns are escalated appropriately
- Build strong working relationships with care homes and teams supporting housebound patients to promote resident wellbeing, coordinate vaccinations, arrange social prescribing visits, and ensure effective communication between all involved providers.
- Arrange wheelchair assessments and referrals and support individuals in accessing appropriate mobility equipment and adaptations.
- Conduct and coordinate Dementia Reviews, including running assessment clinics, supporting carers, gathering input from GPs and community services, and ensuring follow-up actions are completed.
- Deliver NHS Health Check clinics, overseeing the full process from assessment to coordination of results, referrals, and lifestyle interventions to ensure effective follow-through for patients.
- Manage, monitor, and allocate LWT responsibilities across the team, ensuring timely completion, consistent documentation, and effective workflow coordination.
Secondary Responsibilities
- Work alongside practice teams to streamline care for patients with complex or long-term needs, aiming to smooth their journey through the system and accelerate access to appropriate support.
- Use agreed clinical criteria and population health management tools to flag individuals who would benefit from coordinated care, ensuring proactive rather than reactive support.
- Respond to patient queries and provide clear, accessible information that helps them understand and manage their health and care plans.
- Arrange patient appointments as needed and promote vaccination uptake among eligible groups to support prevention and early intervention.
- Tailor support to each person's priorities, ensuring care is sensitive to cultural background, personal values, disabilities and long-term conditions
- Coordinate transitions between different parts of the health and care system, ensuring referrals are timely and that patients move smoothly between services without gaps in support.
- Hold a defined caseload and act as a consistent point of contact for patients across primary care, community services, secondary care and care home environments
- Oversee referrals to clinical and non-clinical services, maintaining effective communication with internal healthcare teams and wider partner organisations.
- Provide calm, practical support to people who feel overwhelmed or uncertain about navigating the care system, helping them build confidence and reduce distress.
- Address health inequalities through focused work with priority groups, including people with multiple health needs or those at higher risk of poor outcomes.
Person Specification
Experience
Essential
- Experience of working in a primary care setting /GP practice - either in a clinical or non-clinical role
- Experience in working and communicating with multiple stakeholders.
- Experience in managing patient case load
- Experience of working in health or social care settings without direct supervision
- Experience of organising and prioritising own workload
- Demonstrates awareness of limits to knowledge base
Desirable
- Experience and understanding of evaluating and measuring the performance of health services.
- Experience in using clinical IT systems, in particular Systmone.
- A good understanding of the health and social care environment and the roles and responsibilities within it.
- Knowledge of existing referral pathways to local health, social care and voluntary organisations.
Qualifications
Essential
- Good standard of education with 5 GCSE's or equivalent.
- NVQ Level 3 in Health & Social Care
- Good IT skills, especially a working knowledge of MS Office (Word,
- Excel, Powerpoint and Outlook).
- Commitment to continuing professional development, including the Personalised Care Institute Course(s).
Desirable
- Qualified in Phlebotomy
- Blood pressure taking
- Experience with vital observations
Skills and Attributes
Essential
- Able to work independently and proactively.
- Be able to manage multiple demands and prioritise appropriately.
- Ability to seek solutions and solve problems using your own initiative.
- Adaptability, flexibility and the ability to cope with uncertainty and change.
- Be able to focus in a busy work environment.
- Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
- Work confidentially and maintain the trust of colleagues and patients.
- Excellent time keeping.
Communication
Essential
- Excellent interpersonal and communication skills.
- Ability and confidence to handle difficult conversations.
- Ability to structure conversations using a coaching approach based on what matters to the person.
- Be able to talk to a wide range of professionals appropriately.
- Ability to nurture key relationships and maintain networks.
Attitude & Behaviour
Essential
- Displays care, compassion, sensitivity and responsiveness to other peoples feelings and needs
- Able to work as part of a team, co-operating to work together and in conjunction with others and willing to help and assist wherever possible and appropriate appreciating the value of diversity in the workplace
- Able to develop, establish and maintain positive relationships with others both internal and external to the organisation and with patients and their carers
- Able to work under pressure, dealing with peaks and troughs in workload.
- Highly motivated and reliable
- Demonstrates values consistent with those of North Wilts Border PCN
Desirable
- Positive and flexible attitude to dealing with change; able to respond to the changing needs of the patient in an appropriate and timely manner;
- willing to change and accept change and to explore new ways of doing things and approaches
- Has a strong degree of personal integrity; able to adhere to standards of conduct based on a culture of equality and fairness
Person Specification
Experience
Essential
- Experience of working in a primary care setting /GP practice - either in a clinical or non-clinical role
- Experience in working and communicating with multiple stakeholders.
- Experience in managing patient case load
- Experience of working in health or social care settings without direct supervision
- Experience of organising and prioritising own workload
- Demonstrates awareness of limits to knowledge base
Desirable
- Experience and understanding of evaluating and measuring the performance of health services.
- Experience in using clinical IT systems, in particular Systmone.
- A good understanding of the health and social care environment and the roles and responsibilities within it.
- Knowledge of existing referral pathways to local health, social care and voluntary organisations.
Qualifications
Essential
- Good standard of education with 5 GCSE's or equivalent.
- NVQ Level 3 in Health & Social Care
- Good IT skills, especially a working knowledge of MS Office (Word,
- Excel, Powerpoint and Outlook).
- Commitment to continuing professional development, including the Personalised Care Institute Course(s).
Desirable
- Qualified in Phlebotomy
- Blood pressure taking
- Experience with vital observations
Skills and Attributes
Essential
- Able to work independently and proactively.
- Be able to manage multiple demands and prioritise appropriately.
- Ability to seek solutions and solve problems using your own initiative.
- Adaptability, flexibility and the ability to cope with uncertainty and change.
- Be able to focus in a busy work environment.
- Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
- Work confidentially and maintain the trust of colleagues and patients.
- Excellent time keeping.
Communication
Essential
- Excellent interpersonal and communication skills.
- Ability and confidence to handle difficult conversations.
- Ability to structure conversations using a coaching approach based on what matters to the person.
- Be able to talk to a wide range of professionals appropriately.
- Ability to nurture key relationships and maintain networks.
Attitude & Behaviour
Essential
- Displays care, compassion, sensitivity and responsiveness to other peoples feelings and needs
- Able to work as part of a team, co-operating to work together and in conjunction with others and willing to help and assist wherever possible and appropriate appreciating the value of diversity in the workplace
- Able to develop, establish and maintain positive relationships with others both internal and external to the organisation and with patients and their carers
- Able to work under pressure, dealing with peaks and troughs in workload.
- Highly motivated and reliable
- Demonstrates values consistent with those of North Wilts Border PCN
Desirable
- Positive and flexible attitude to dealing with change; able to respond to the changing needs of the patient in an appropriate and timely manner;
- willing to change and accept change and to explore new ways of doing things and approaches
- Has a strong degree of personal integrity; able to adhere to standards of conduct based on a culture of equality and fairness
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.
