The post holder working closely with the GPs, Community Services, PCN Team, and Care Home Team where appropriate will: Be responsible for daily updating of patients on Workflow to identify patients to support the PCN team with correct community pathways that may prevent hospital admission and to identify potential gaps in care To record patient interventions on relevant electronic database systems and contribute to report generation, analysis and production Follow up on all forward actions. Be responsible for logging and making referrals To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the PCN Team and providing information to any member of the PCN Team in order to ease processes and communication in agreement with data protection protocol To be customer (patient, carer, GP) focused when representing the service To work collaboratively with other teams and services to maintain an effective and efficient service To offer appropriate support and guidance to patients and their families/carers To plan / organise work using own initiative, whilst being able to work as a valuable member of a team To have excellent IT skills, to include Microsoft Office, Outlook and Excel To undertake general office duties to support the role To work effectively as part of a team to provide cover for Care Navigation and PCN Care Coordinators when required and to be flexible regarding working hours to meet the needs of the service To ensure all electronic records are updated and complete within the agreed time-scales To use a range of verbal and non-verbal communication tools to communicate effectively with patients, carers and families and colleagues Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support where requested Work towards completing the appropriate training. To participate in the review and appraisal process To carry out any other reasonable duties as requested by a manager to ensure quality of service To participate in any relevant training/courses/conferences Complete mandatory training