Core Duties Provide the PCN with support to identify patients and engage patients to attend for an NHS health check and support in practice clinics, including 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 delivery of personalised care. Support the achievement of the IIF targets through reporting and communication. Additional Duties Daily updating of patients on e-HealthScope Workflow to support the PCN team with identifying community pathways that might prevent hospital admission and for identifying potential gaps in care. Record patient interventions on relevant electronic database systems (e.g. SystmOne) and contribute to report generation, analysis and production. Contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team. Use clinical systems for record keeping, audit and evaluation. Be customer (patient, carer, GP) focused when representing the service. Work collaboratively with other teams and services to maintain an effective and efficient service. Offer appropriate support and guidance to patients and their families/carers. Plan/organise work using own initiative, while being a valuable team member. Provide cover for Care Coordination Teams when required and be flexible regarding working hours to meet service needs. Ensure all electronic records are updated and complete within agreed time-scales. Use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers, families, and colleagues. 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. Participate in any relevant training/courses/conferences. Complete mandatory training and adhere to organisational policies and procedures, including confidentiality, safeguarding, information governance, and health and safety.