As a Care Coordinator you will work as a key part of the Primary Care multi-disciplinary team. You will ensure care is seamless and that everyone involved is working together. You will provide the capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals.
You will assist practice in our ambition to improve the quality and continuity of care by acting as a point of contact and coordinating annual reviews for patients with chronic conditions, participating in meetings and timely intervention as part of the MDT for the practice. You will assist with documents review and clinical coding as well as prescribing. You will support the practice in developing a support to care homes and work towards the ongoing COVID Vaccination & Flu Vaccination Programme.
Main duties of the job
Your role is an essential part of our evolving dynamic and forward-thinking practice, working to provide enhanced care experience to patients in line with a view to improving health inequalities. Other duties may include:
* Act as a point of contact between GP, patients and carers and other agencies.
* Liaise with GPs and practice teams to identify patients who are elderly, frail or who have long term health needs and support.
* Develop use of Group Consultations to help support the care arrangements for patients with long term conditions, i.e. COPD, Asthma, Diabetes.
* Support patients to access community care assessments as well as carers assessments.
* Assist with managing patients to reduce unplanned hospital admissions where appropriate.
* Where necessary, participate in MDT meetings to discuss patients actively being managed by the Care Homes Team and any other patients from the PCNs case load needing discussion.
* Raise awareness of health promotion & screening such as NHS Health Checks and LD Health Checks in practices and coordinate invitations to ensure targets are achieved on a practice and PCN level.
* Assist and manage recall system for chronic diseases, acting as a point of contact for any queries regarding routine annual reviews.
* Assist with ongoing monitoring of PCN requirements including IIF and QOF across the PCN practices.
* Run audits and searches where necessary to identify patients for review.
* Clinical document review and clinical coding, ensuring coding is in line with current contract requirements. Participate in document review audits and meetings.
* Assist with daily prescriptions and act as a deputy to prescribing admin lead.
* Assist and coordinate clinics where necessary, and contact identified patients with appointments.
* Manage patient initiated calls for help/signposting, ensuring patients are directed to appropriate service including liaising with other professionals e.g. Social Prescribers.
* Document and monitor aspects of patient coordination and service delivery supporting data collection and audit using the practices clinical system.
* Demonstrate the ability to recognise and respond appropriately when faced with a sudden deterioration or emergency situation, alerting the team or enabling a rapid response.
* Support and raise awareness of national screening and immunisation programmes and encourage uptake.
* Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact.
* Work closely with and refer to PCN social prescribing link workers where a patient is identified as potentially benefitting from this service.
About The Candidate
This role requires a dedicated self-starter enthusiastic to work with practices at scale. You will need to have the following skills / qualifications:
* You will have experience of working within healthcare or the voluntary/community sector, supporting vulnerable groups.
* Ideally you will have a Diploma Level 2 in Health and Social Care or equivalent qualification.
* Excellent IT skills including Microsoft Office and experience with GP Clinical System (Emis or equivalent).
* Experience in clinical coding and prescribing in primary care.
* Strong listening and communication skills.
* Ability to work well in a team but also able to work independently without supervision.
* You will be able to review and improve working practices with shared experience across the practice and wider PCN.
* You will be familiar with local resources and services and how to access them.
* You will be motivated by helping people, with care and empathy.
* In delivering person-centered support in a non-judgmental way.
* Experience of completing holistic person-centered care planning assessments.
Person Specification
Qualifications
* See Person Specification in attached Job Descriptions.
Experience
* Experience working in General Practice is desirable but not essential.
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.
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