Job Responsibilities: Utilise population health intelligence to proactively identify and work with the priority group of patients to deliver personalised care Support the practices in delivering their outcome targets for both the LD and SMI populations Lead for prevention and tackling of health inequalities. Bringing together key agencies to ensure multi-disciplinary teams tackle any issues that prevent people having access to appropriate healthcare 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. Provide coordination and navigation for people and their carers across health and care services, working closely with Community Link Advisers, Wellbeing Practitioners, Mental Health Practitioners and other primary care professionals. 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 Organise and support the Multi-Disciplinary Meetings across the 4 PCN Practices. The post holder would be expected to undertake the course accredited by the Personalised Care Institute. Health and Safety To comply with the Health and Safety at Work etc. Act 1974. To take responsibility for his/her own health and safety and that of other persons who may be affected by his/her own acts or omissions. Equality and Diversity To carry out at all times his/her responsibilities in line with the Equal Opportunities Policy and Procedure. Risk Management and Clinical Governance To work within the Clinical Governance Framework of the practice, incorporating Risk Management and all other quality initiatives. Confidentiality To maintain confidentiality of information relating to patients, clients, staff and other users of the services working to the remits of Confidentiality and the General Data Protection Regulations. Any breach of confidentiality may render an individual liable for dismissal and/or prosecution. General To work across Primary Care Network sites as required.