Key Responsibilities: Care Coordination & Social Prescribing: Develop person-centred care plans that reflect individual needs, preferences, and aspirations. Refer and signpost patients to a range of non-clinical services, such as social support groups, community initiatives, housing advice, and wellbeing programs. Support people to become more confident in managing their own health and social needs. Liaise with GPs, nurses, allied health professionals, and social care teams to coordinate care delivery. Promote patient self-management, choice, and empowerment through motivational conversations and health coaching techniques. Follow up with patients and services to monitor progress and address any barriers to engagement. Clinical System & Performance Support: Run clinical system searches to support population health management, including long term condition reviews. Contact patients as part of recall systems for QOF, IIF, vaccination, and long-term condition reviews. Monitor practice performance against QOF, IIF, enhanced services, and other relevant metrics. Extract key clinical information from hospital letters and correspondence, ensuring accurate coding into patient records.