Overview
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Job Summary
We are seeking an enthusiastic and organised Care Coordinators to join the growing multi-disciplinary team within the North Wilts Border Primary Care Network (PCN). Building on our successful care coordination model, this role is key to delivering personalised, joined-up care for our patients.
As a Care Coordinator, you will work closely with PCN practices and a wide range of health professionals including GPs, nurses, paramedics, pharmacists, and others. You will be responsible for coordinating access to services, information, and support ensuring that care is timely, efficient, and centred around the needs of each patient.
This Is a Vital Role That Contributes Directly To:
* Enhancing patient experience and outcomes
* Preventing avoidable hospital admissions
* Supporting the NHS Long Term Plan and PCN priorities through integrated, person-centred care
You will act as a key point of contact, helping to bridge the gap between patients and clinical teams. Your work will help free up valuable clinical time while ensuring that patients feel informed, supported, and confident in managing their own health and wellbeing.
Main duties of the job
* Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
* Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan.
* 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, including through the use of the Patient Activation Measure
* Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level
* Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals
* Support the coordination, administration and delivery of MDTs within the PCN and to work as a key member of the MDT to help support the development of effective MDT meetings.
* 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.
About Us
North Wilts Border PCN is a collaborative NHS partnership made up of six GP surgeries, working together to deliver high-quality, patient-centred care to over 54,000 people across our local communities. We are proud to be rooted in our community and are committed to staying connected with and supporting the people we serve.
In addition to our dedication to clinical excellence, we are also a teaching and training network, supporting medical students from the University of Bath and GP trainees from across the South West region.
Our diverse multidisciplinary team includes Specialist Practitioners, Health & Wellbeing Coaches, Care Coordinators, and Clinical Directors. We place great value on the contributions of our Living Well team and are committed to supporting the personal and professional development of all staff.
What We Offer
* A supportive and inclusive team culture that is well-led
* Opportunities for professional development and leadership
* Flexible working arrangements
* Access to mentorship and clinical supervision
* Involvement in innovative projects and service development
* Employee Assistant programme
* NHS Pension
* Cost coverage of an Enhanced DBS
* Excellent Induction
* 25 days annual leave pro rata
Details
* Date posted: 06 September 2025
* Pay scheme: Other
* Salary: Depending on experience
* Contract: Permanent
* Working pattern: Full-time
* Reference number: W0050-25-0005
Job locations
* Tinkers Lane Surgery, Tinkers Field, Royal Wootton Bassett, Swindon, Wiltshire, SN4 7AT
* Doctors Surgery, Willis Way, Purton, Swindon, SN5 4BD
* The Surgery, 113 High Street, Cricklade, Swindon, SN6 6AE
* New Court Surgery, Borough Fields Shopping Centre, Royal Wootton Bassett, Swindon, Wiltshire, SN4 7AX
* Malmesbury Primary Care Centre, Priory Way, Malmesbury, Wiltshire, SN16 0FB
* The Tolsey Surgery, High Street, Sherston, Malmesbury, Wiltshire, SN16 0LQ
Job Description
Primary Responsibilities
* Work with practice teams to coordinate care for patients with more complex or ongoing needs, improving the patient journey and expediting care where necessary.
* Proactively identify patients requiring care coordination using agreed criteria, population health management tools, and clinical input.
* Support patients in accessing benefits, training, and employment opportunities where appropriate.
* Help patients manage their health by responding to queries and ensuring access to clear, quality information about their care.
* Coordinate appointments and encourage the uptake of vaccinations among eligible groups.
* Focus on what matters most to each individual patient, ensuring support is personalised and culturally sensitive, especially for people from diverse backgrounds and those living with disabilities or long-term conditions.
* Navigate and coordinate care across health and care systems ensuring timely, appropriate referrals and seamless transitions between services.
* Manage a caseload of patients, acting as their single point of contact across primary care, community care, secondary care, and care home settings.
* Facilitate and monitor referrals to both clinical and non-clinical services, working closely with healthcare teams and external partners.
* Empower and enable patients to manage their own care and take an active role in their health and wellbeing.
* Support people who may be anxious, confused, or overwhelmed by the care system, helping reduce stress and build confidence.
* Liaise with Adult Social Care when required to raise safeguarding concerns or request care assessments.
* Tackle health inequalities through targeted work with identified population groups, such as those with long-term conditions or multiple health needs.
* Uphold all relevant policies and procedures, including safeguarding, confidentiality, lone working, information governance, health and safety, and equality, diversity and inclusion.
Secondary Responsibilities
* In addition to the primary responsibilities, the Care Coordinator may be requested to:
* Support the PCN audit programme & undertaking audits when necessary
* Support junior members of the team, providing guidance when necessary
* Participate in local initiatives to enhance service delivery and patient care
* Support and participate in shared learning across the practice
* Participate in PCN projects as directed by PCN manager
* Take personal responsibility for own learning and development, including the requirement to maintain competency, achieving all targets set in own Personal Development Plan (PDP)
Person Specification
Experience
Essential
* Experience of working in a primary care setting /GP practice - either in a clinical or non-clinical role
* Experience in working and communicating with multiple stakeholders.
* Experience in managing patient case load
Desirable
* Experience and understanding of evaluating and measuring the performance of health services.
* Experience in using clinical IT systems, in particular Systmone.
* A good understanding of the health and social care environment and the roles and responsibilities within it.
* Knowledge of existing referral pathways to local health, social care and voluntary organisations.
Qualifications
Essential
* Good standard of education with 5 GCSE's or equivalent.
* Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint and Outlook).
* Commitment to continuing professional development, including the Personalised Care Institute Course(s).
Desirable
* Qualified in Phlebotomy
* NVQ Level 3 in Health & Social Care
Skills and Attributes
Essential
* Able to work independently and proactively.
* Be able to manage multiple demands and prioritise appropriately.
* Ability to seek solutions and solve problems using your own initiative.
* Adaptability, flexibility and the ability to cope with uncertainty and change.
* Be able to focus in a busy work environment.
* Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
* Work in a confidential manner and maintain the trust of colleagues and patients.
* Excellent time keeping.
Communication
Essential
* Excellent interpersonal and communication skills.
* Ability and confidence to handle difficult conversations.
* Ability to structure conversations using a coaching approach based on what matters to the person.
* Be able to talk to a wide range of professionals appropriately.
* Ability to nurture key relationships and maintain networks.
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.
Employer details
North Wilts Border PCN Ltd Company
Address: Tinkers Lane Surgery, Tinkers Field, Royal Wootton Bassett, Swindon, Wiltshire, SN4 7AT
Employer's website: https://northwiltsborderpcn.nhs.uk/
Seniority level
* Entry level
Employment type
* Full-time
Job function
* Other
Industries
* Hospitals
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