Job summary 23 hours per week, days to be agreed, but Fridays are required Candidates will need to be a team player with a passion for giving excellent customer service. This role will be managing our chronic disease register and will require good data awareness and personal skills. A good understanding of Quality outcome Framework (QOF) targets along with a working knowledge of EMIS is desirable. Previous experience gained within the NHS, promoting attendance at Health Promotion clinics, ensuring patients are called for reviews in a timely manner and carry out basic searches is preferred. Main duties of the job The purpose of the role is o work as part of the QOF team and support the clinicians at Tyntesfield Medical Group to achieve all QOF targets annually. About us Tyntesfield Medical Group in North Somerset is a 13 Partner General Practice with a patient list size currently of around 33,000 split across four sites: Tower House Medical Centre, Brockway Medical Centre, Backwell Medical Centre and Long Ashton Surgery. We are a friendly and accessible team providing excellent healthcare in our community. We provide a professional, safe, supportive, and efficient working environment for everyone in the practice. We are a forward-thinking organisation with a strong emphasis on teamwork and patient-centred care. Date posted 14 April 2025 Pay scheme Other Salary £12.48 an hour Contract Permanent Working pattern Part-time Reference number A0519-25-0004 Job locations Backwell Medical Centre 15 West Town Road Backwell Bristol BS48 3HA Job description Job responsibilities Co-ordinate care for disease prevention and actively promote attendance at Health Promotion clinics Have a good understanding of QOF targets and ensure patients are called for review in a timely manner Regularly search for patients with poor disease control and target them for additional support, e.g., for weight loss/drug compliance/overdue blood tests or other investigations Actively search for patients with a high BMI or smokers to support to change Refer signpost patients to smoking cessation, exercise and weight loss services Liaise with the Social Prescribing Team (Wellbeing Team) when required Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care Help patients to manage their needs through answering queries, making and managing appointments Work with the GPs and other primary care professionals to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals Discuss patient related concerns with a GP where required Support pre-diabetic patients to ensure annual HbA1c and referral to National Diabetes Prevention Programme education where necessary To improve the Population Health Management within the practice to enable better clinical outcomes Ensure the health promotion clinics are used efficiently and effectively by actively managing clinic bookings and patient recall. The support would include: Ensure early follow up for diabetic review if needed more frequently than annually Ensure the patient has the most efficient appointment if they have co-morbidities to improve engagement and compliance Invite patients on the Learning Disability register for the first part of their annual review with the QOF Team and book the second part Send reminders to patients overdue their cancer screening (breast, bowel, cervical, PSA) Coordinate long term condition monitoring for housebound patients Create and edit EMIS searches Claim on behalf of practice: CQRS, Local Enhanced Services, Public Health, PPA prescriptions Job description Job responsibilities Co-ordinate care for disease prevention and actively promote attendance at Health Promotion clinics Have a good understanding of QOF targets and ensure patients are called for review in a timely manner Regularly search for patients with poor disease control and target them for additional support, e.g., for weight loss/drug compliance/overdue blood tests or other investigations Actively search for patients with a high BMI or smokers to support to change Refer signpost patients to smoking cessation, exercise and weight loss services Liaise with the Social Prescribing Team (Wellbeing Team) when required Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care Help patients to manage their needs through answering queries, making and managing appointments Work with the GPs and other primary care professionals to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals Discuss patient related concerns with a GP where required Support pre-diabetic patients to ensure annual HbA1c and referral to National Diabetes Prevention Programme education where necessary To improve the Population Health Management within the practice to enable better clinical outcomes Ensure the health promotion clinics are used efficiently and effectively by actively managing clinic bookings and patient recall. The support would include: Ensure early follow up for diabetic review if needed more frequently than annually Ensure the patient has the most efficient appointment if they have co-morbidities to improve engagement and compliance Invite patients on the Learning Disability register for the first part of their annual review with the QOF Team and book the second part Send reminders to patients overdue their cancer screening (breast, bowel, cervical, PSA) Coordinate long term condition monitoring for housebound patients Create and edit EMIS searches Claim on behalf of practice: CQRS, Local Enhanced Services, Public Health, PPA prescriptions Person Specification Qualifications Essential Demonstrates good standard of written and spoken English Skills and Knowledge Essential Customer service skills Good keyboard / IT skills literate with Microsoft Word and Outlook, and able to adapt to using third-party software Ability to work independently, with minimal supervision, including initiating actions, implementing decisions, monitoring and reporting Clear understanding of data protection requirements and participant confidentiality Good written and verbal communication skills Experience Essential Quickly building trust and a positive dialogue with individuals who face challenges about their health A flexible approach and a focus on what matters for an individual Produce promotional material, monitoring information and producing reports Experience using EMIS Desirable Working within the health sector Promoting Health Promotion clinics Inviting patients for reviews Carrying out basic searches Referring / signposting patients Good understanding of QoF Personal Attributes Essential Willingness to undertake any training as required in relation to the role To work as part of a team and on own using initiative Organise own time, manage workload & meet deadlines, working flexibly when required Desirable Possessing the ability to portray, by personal example, the benefits of pursing a healthier lifestyle Possessing a 'can do' and 'will do' attitude Person Specification Qualifications Essential Demonstrates good standard of written and spoken English Skills and Knowledge Essential Customer service skills Good keyboard / IT skills literate with Microsoft Word and Outlook, and able to adapt to using third-party software Ability to work independently, with minimal supervision, including initiating actions, implementing decisions, monitoring and reporting Clear understanding of data protection requirements and participant confidentiality Good written and verbal communication skills Experience Essential Quickly building trust and a positive dialogue with individuals who face challenges about their health A flexible approach and a focus on what matters for an individual Produce promotional material, monitoring information and producing reports Experience using EMIS Desirable Working within the health sector Promoting Health Promotion clinics Inviting patients for reviews Carrying out basic searches Referring / signposting patients Good understanding of QoF Personal Attributes Essential Willingness to undertake any training as required in relation to the role To work as part of a team and on own using initiative Organise own time, manage workload & meet deadlines, working flexibly when required Desirable Possessing the ability to portray, by personal example, the benefits of pursing a healthier lifestyle Possessing a 'can do' and 'will do' attitude 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 Tyntesfield Medical Group Address Backwell Medical Centre 15 West Town Road Backwell Bristol BS48 3HA Employer's website https://www.tyntesfield.nhs.uk/ (Opens in a new tab)