Key duties include, but are not limited to: - Inviting selected cohorts of patients in for routine monitoring Being a key contact for patients with complex and/or long-term healthcare needs Liaising with local care homes on a weekly basis Reviewing missed childhood immunisations Carry out audits to identify improvements and maximise income particularly IIF, Enhanced Service and claiming procedures. Use Ardens and other appropriate population health dashboards and tools to help deliver the population health management projects Design efficient templates, protocols, alerts, and other IT tools to support safety, patient care, quality record-keeping, reporting and financial claims To assist people to access self-management education courses To provide co-ordination and navigation for people and their carers across health and care services To work closely with Social Prescribing Link Workers and other primary care professionals To 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. To raise awareness within the PCN of shared decision making and decision support tools; and how to identify patients who may benefit from shared decision making To be able to plan and respond to workload according to operational priorities.