Hours: 24 Hours per week Monday - 9.00 am - 3.00 pm Tuesday - Day Off Wednesday - 9.00 am - 3.00 pm Thursday - 9.00 am - 3.00 pm Friday - 9.00 am - 3.00 pm Responsible & Accountable to:Operations Manager Location:Yorkley Health Centre & Bream Surgery 1.0 Job Purpose The post holder will be working for the benefit of patients, providing and maintaining high standards of care for patients health needs. The post holder will carry out referrals to secondary care and other agencies and support the clinical staff to deliver desired standards of care to the patient population. The post holder will become an integral part of the Practice multidisciplinary team, working alongside social prescribing link workers and other community providers to provide an all-encompassing approach to personalised care. 2.0 Main Duties and Responsibilities Implement processes for practices to proactively identify and work with patients, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. Work closely with GPs and practice teams to support them to manage a caseload of patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers, helping them to understand and manage their condition and ensure changing needs are addressed. Provide admin support for all GPs including dealing with private medical and insurance reports, occupational health and medical reports and associated paperwork. Review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. Assist GPs with referrals and other administrative tasks. Liaise with Social Prescribing Link Workers and Complex Care @ Home on current health resource and future work. Liaise and work with the ICB, practices, Integrated Locality Team, voluntary and other organisations to implement patient services. Co-ordinate Care Home Multi-disciplinary Team (MDTs) meeting and submit quarterly claim to the Primary Care Network (PCN) Business Manager in liaison with the Finance Manager. Support the practice and PCN in achieving QOF, DES and IIF targets and collating data. Involvement in Peer Review Meetings and Quality Improvement projects (for example Prescribing, cancer Care QOF, etc). Coordinate practice attendance at various MDT meetings (eg Dementia, Respiratory and Pain Management). Facilitate effective communication and engagement with the PCN and act as practice link (in liaison with senior staff) with the PCN Project Team. Support the PCN with the delivery of improved population health outcomes. Raise awareness of health promotion in practices, implementing, co-ordinating and supporting a variety of projects. Support the nursing team with admin tasks/searches and patient recalls for long term condition reviews (LTC). Support patients medical record access (NHS app) implementation and redaction of data as and when needed, providing copies of medical records when needed. Support note summarising. Provide admin support to all of the teams as and when needed.