Job summary Job summary The Clinical Care Coordinator will be employed by Synergy Health PCN to work on behalf of the three member practices. Synergy Health PCN has a sizeable cohort of patients eligible for an NHS health Check, as well as using population health management to target patients for preventable measures. The role would also work within the PCN team and provide administration support to the practices and support in the coordination and delivery of multidisciplinary team meetings. Primary Care Networks (PCN) are local neighbourhoods where all health and social care services work together to deliver a better experience for their citizens. Main duties of the job Core Duties To provide the PCN with support to identify patients and engage patients to attend for an NHS health check and support in practice clinics. (To include basic clinical skills such as taking blood tests, blood pressure, height, weight, urine dip and lifestyle questions). Coordinate Multi-Disciplinary Team meetings for people living in the community. Be responsible for arranging, attending and minuting Multi-Disciplinary Team Meetings. Follow up on all forward actions resulting from MDT discussions Utilise Population Health Intelligence to proactively identify patients at risk and work with the PCN team to enable the PCN team to deliver personalised care Utilise Population Health Intelligence tools where needed to support other patients in the PCN. Support the achievement of the IIF targets through reporting and communication About us Synergy Health PCN covers three practices in Gedling, Jubilee Park Medical Partnership in Carlton with a branch site in Lowdham, West Oak on Westdale Lane, Mapperley and Trentside Medical Group in Netherfield and Carlton. We are a standalone PCN with a lead practice. We have a population of 36,000 patients. The PCN has care co-ordinators, social prescribing link workers and are recruiting for a health and wellbeing coach. These roles will work closely together as the PCN holistic care team. Our vision is to build and develop collaborative working across member practices and stakeholders, to support and strengthen the delivery of Primary Care services and improve health outcomes for the local population we serve. Date posted 07 February 2025 Pay scheme Other Salary £24,000 to £25,650 a year Contract Permanent Working pattern Flexible working Reference number A5713-25-0000 Job locations Trentside Medical Group Knight Street Netherfield Nottingham NG4 2FN West Oak Surgery 319 Westdale Lane Mapperley Nottingham NG3 6EW Park House Medical Centre 61 Burton Road Carlton Nottingham NG4 3DQ Job description Job responsibilities RESPONSIBILITIES Core Duties To provide the PCN with support to identify patients and engage patients to attend for an NHS health check and support in practice clinics. (To include basic clinical skills such as taking blood tests, blood pressure, height, weight, urine dip and lifestyle questions). Coordinate Multi-Disciplinary Team meetings for people living in the community. Be responsible for arranging, attending and minuting Multi-Disciplinary Team Meetings. Follow up on all forward actions resulting from MDT discussions Utilise Population Health Intelligence to proactively identify patients at risk and work with the PCN team to enable the PCN team to deliver personalised care Utilise Population Health Intelligence tools where needed to support other patients in the PCN. Support the achievement of the IIF targets through reporting and communication Additional Duties Be responsible for daily updating of patients on e-HealthScope Workflow to identify patient to support the PCN team with identifying community pathways that might prevent hospital admission and for identifying potential gaps in care To record patient interventions on relevant electronic database systems (e.g. SystmOne) and contribute to report generation, analysis and production To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol Use clinical systems for record keeping, audit and evaluation To be customer (patient, carer, GP) focused when representing the service To work collaboratively with other teams and services to maintain an effective and efficient service To offer appropriate support and guidance to patients and their families/carers To plan / organise work using own initiative, whilst being able to work as a valuable member of a team To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service To ensure all electronic records are updated and complete within the agreed time-scales To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues. To support and work with key personnel in the PCN to develop & support collective general practice projects. Professional Development / Personal Performance Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care. To participate in any relevant training/courses/conferences Complete mandatory training Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Job description Job responsibilities RESPONSIBILITIES Core Duties To provide the PCN with support to identify patients and engage patients to attend for an NHS health check and support in practice clinics. (To include basic clinical skills such as taking blood tests, blood pressure, height, weight, urine dip and lifestyle questions). Coordinate Multi-Disciplinary Team meetings for people living in the community. Be responsible for arranging, attending and minuting Multi-Disciplinary Team Meetings. Follow up on all forward actions resulting from MDT discussions Utilise Population Health Intelligence to proactively identify patients at risk and work with the PCN team to enable the PCN team to deliver personalised care Utilise Population Health Intelligence tools where needed to support other patients in the PCN. Support the achievement of the IIF targets through reporting and communication Additional Duties Be responsible for daily updating of patients on e-HealthScope Workflow to identify patient to support the PCN team with identifying community pathways that might prevent hospital admission and for identifying potential gaps in care To record patient interventions on relevant electronic database systems (e.g. SystmOne) and contribute to report generation, analysis and production To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol Use clinical systems for record keeping, audit and evaluation To be customer (patient, carer, GP) focused when representing the service To work collaboratively with other teams and services to maintain an effective and efficient service To offer appropriate support and guidance to patients and their families/carers To plan / organise work using own initiative, whilst being able to work as a valuable member of a team To work effectively as part of a team to provide cover for Care Coordination Teams when required and to be flexible regarding working hours to meet the needs of the service To ensure all electronic records are updated and complete within the agreed time-scales To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues. To support and work with key personnel in the PCN to develop & support collective general practice projects. Professional Development / Personal Performance Work towards completing the appropriate training to deliver and support the Comprehensive Model for Personalised Care. To participate in any relevant training/courses/conferences Complete mandatory training Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Person Specification Experience Essential Please refer to the job description and person specification attached to the job advert. Desirable Please refer to the job description and person specification attached to the job advert. Qualifications Essential Please refer to the job description and person specification attached to the job advert. Desirable Please refer to the job description and person specification attached to the job advert. Person Specification Experience Essential Please refer to the job description and person specification attached to the job advert. Desirable Please refer to the job description and person specification attached to the job advert. Qualifications Essential Please refer to the job description and person specification attached to the job advert. Desirable Please refer to the job description and person specification attached to the job advert. 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 Synergy Health PCN Address Trentside Medical Group Knight Street Netherfield Nottingham NG4 2FN Employer's website https://healthandcarenotts.co.uk/care-in-my-area/south-nottinghamshire-pbp/south-nottinghamshire-pcns/synergy-health/ (Opens in a new tab)