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Job Summary

Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.

They can be an effective intervention in supporting people to stay well particularly those with long term conditions, multiple long-term conditions, and people living with or at risk of frailty.

Main duties of the job

Working closely with GPs, Community Services, Care Homes and Practice Teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to patients and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. We are seeking Care Coordinators to work in the following service areas: Enhanced Health at Home.

Key Responsibilities:

  • Work with people, their families, and carers to improve their understanding of the patient’s condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes
  • 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
  • Support people to understand their level of knowledge, skills, and confidence, when engaging with their health and wellbeing
  • Work as part of the multidisciplinary team, building relationships with staff in GP practices within the PCN, care homes & other organisations.

About us

Within South Sefton PCN our aims are to:

  • Improve resilience in General Practice
  • Build a stronger and more sustainable general practice service across the Primary Care Network footprint
  • Facilitate collaborative working between all Primary Care Network practices
  • Engage with local health and care providers to develop place-based care to assist in the transformation of local services to improve the health and wellbeing of the Primary Care Network population
  • Work with Patient Participation Groups to improved patient access, experience and quality
  • Reach out to strengthen and develop working relationships with non-NHS community groups
  • Develop signposting with Primary Care Network practices to streamline the patient journey to enhance more achievable and sustainable outcomes
  • Further develop digital technology as a primary resource for practices and patients
  • Work in collaboration with the local GP Federation to build and strengthen relationships

Job description

Job responsibilities

As Care Coordinator your key responsibilities will include, but not be limited to:Multidisciplinary Team (MDT)

1. Arrange the EHAH led Huddles/MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting. Record actions agreed at the meetings or take minutes and circulate as required.2. Consult with all members of the MDT to ensure its effective function.3. Work closely within the PCN roles, Community Services, Community Matron, MDT and with GP practices within the PCN to ensure that the comprehensive records of MDT case discussions are entered into clinical systems, adhering to data protection legislation and datasharing agreements.4. Work as part of the MDT and wider PCN / Care Community to achieve its ICP (integrated care provider) directed objectives.


5. As part of the PCN MDT, build relationships with staff in each GP Practice within the PCN, attending practice meetings as required providing information and feedback on care coordination priorities.

6. Consult directly with Community services, Acute Trust Ward Managers, Social Care, Practice staff and other key providers to identify patients for discussion at MDT, and compile and circulate relevant information to attendees.

7. Refer patients to local services as required utilising providers referral processes.

Working with patients

8. Using clinical systems and data analysis to ensure a proactive approach to identifying patients that would benefit from review.

9. Alerting, referring or liaising with the relevant Service, Community Matron, professionals, family, and other services as required.

10. Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision making conversation.

11. Work with patients, Carers, and professionals to deliver personalised care and support planning for patients.

12. Help people to manage their needs through answering queries, making, and managing appointments and ensure that patients have excellent quality information to help them make choices about their care.

13. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the tools.

14. Provide co-ordination and navigation for patients and their carers across health and care services, consulting with practice and PCN staff including social prescribing link workers and health and wellbeing coaches.

15. Seek advice and support from the Community Matron/GP supervisor/Clinical Lead and/or identified individual(s) to discuss patient related concerns (e.g. abuse, domestic violence, and support with mental health), referring the patient back to the GP or other suitablehealth professional if required.

16. To manage communications and social media pages to ensure patients have relevant and timely information to help them manage their health needs.

Personal/Professional development:

The post-holder will participate in any training programme implemented by the practice as part of this employment, with such training toinclude:

Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.Complete mandatory training during probationary period.


The post-holder will strive to maintain quality within the service and will:

Alert other team members to issues of quality and risk.Assess own performance and take accountability for own actions, either directly or under supervision.Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.Work effectively with individuals in other agencies to meet patients needs.Effectively manage own time, workload and resources.

Communication:The post-holder should recognise the importance of effective communication within the team and will strive to:

Communicate effectively with other team members.Communicate effectively with patients and carers.Recognise peoples needs for alternative methods of communication and respond accordingly.

Contribution to the implementation of services:

The post-holder will:Apply all policies, standards and guidance.Discuss with other members of the team how the policies, standards and guidelines will affect own work.Participate in audit where appropriate.

Work with practices and patients to fulfil SMI health checks, long term condition management & LD health checks

This role is an expanding role that may require input into additional programmes and services

Person Specification

Education & Qualifications


  • Relevant qualification or experience in a similar role within health or social care
  • grade A to C in English and Math’s or equivalent level
  • Qualified to NVQ level 2 in Health and Social Care (or similar) Diploma/ HNC level (or relevant experience) or NVQ Level 2 Business Administration (or relevant experience)
  • A current driving license and access to a vehicle


  • Qualification in Health or Social care allied profession
  • Qualified to NVQ level 3 or Qualified to Degree level
  • Further professional development
  • Be able to undertake training as a Trusted Assessor

Knowledge & Skills


  • Effective communication and people skills including good telephony skills
  • Ability to work well in a multi-disciplinary team
  • Good organisational and time management skills including planning, prioritising, time management and record keeping
  • Ability to demonstrate a professional, positive attitude and work ethic
  • Knowledge of and ability to comply with data integrity, confidentiality, and security to safeguard all personal identifiable information
  • Excellent interpersonal skills and ability to interact professionally with people from diverse cultural, racial, ethnic, gender, and socioeconomic backgrounds during a time of crisis and distress
  • Ability to show empathy and be non-judgmental toward individuals
  • Demonstrates an understanding of, and commitment to, equality, diversity, and inclusion
  • Ability to recognise and work within limits of competence and seek advice when needed
  • Proven ability to recognise and manage risk


  • Understands the wider determinants of health, including social, economic, and environmental factors and their impact on communities, individuals, their families, and carers
  • Knowledge of how the NHS works, including primary care and PCNs
  • Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
  • Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional, and social
  • Proficiency in navigating computer systems with the ability to learn new data systems quickly
  • Data management skills
  • Project management skills



  • Experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field (including unpaid work) and/or industry where you have worked with people or customers


  • Experience working in an NHS setting and/or experience of working with or in general practice
  • Experience of supporting people, their families, and carers in a related role (including unpaid)
  • Experience with managing IT systems
  • Experience of data collection and using tools to measure the impact of services

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.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Closing Date: 09 June 2024

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