Job Summary
Care coordinators play an important role within the surgery to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Main duties of the job
Enhance inclusivity by improving access to difficult to contact patients, such as the homeless and those who cannot get transport.
Act as safeguarding administrator working closely with the Doctors, health visitors and school nurse to organising quarterly safeguarding meetings, take minutes and support actions that need to take place.
Support reception with Care Navigation and be available to the Same Day Team for support.
Support patient care between internal departments and external services to navigate them through the care system.
Provide coordination and navigation for people, especially vulnerable patients or those with complex needs, and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
Engage with other healthcare providers and fill out referral forms for patient support services, such as for wheelchairs, Occupational Therapy or Care Farms for example.
Identify unpaid carers and help them access services to support them
Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
About Us
Cutlers Hill Surgery is a rural practice with approximately 10500 patients. We are a part of the South Waveney Alliance Network (SWAN).We have a well-established practice team including 4 GPS, 4 UCPs, one of which specialises in home visiting, 4 Nurse Practitioners, 4 Practice Nurses, 2 HCAs, 2 physios, 2 Mental Health practitioners, 2 clinical pharmacists, and a Social Prescriber, along with a fantastic administrative team. The practice is committed to innovation, development and providing excellent patient care. We are looking for a dedicated professional who shares the same values to join us.
Details
Date posted
11 August 2025
Pay scheme
Other
Salary
Depending on experience
Contract
Permanent
Working pattern
Part-time, Flexible working
Reference number
A2591-25-0001
Job locations
Cutlers Hill Surgery
Bungay Road
Halesworth
Suffolk
IP19 8SG
Job Description
Job responsibilities
Summary
Care coordinators play an important role within the surgery to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Responsibilities
Enhance inclusivity by improving access to difficult to contact patients, such as the homeless and those who cannot get transport.
Following up low tier mental health disorders and supporting the mental health clinicians.
Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Act as safeguarding administrator working closely with the Doctors, health visitors and school nurse to organising quarterly safeguarding meetings, take minutes and support actions that need to take place.
Support reception with Care Navigation and be available to the Same Day Team for support.
Support patient care between internal departments and external services to navigate them through the care system.
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.
Work collaboratively with GPs and other primary care professionals within the surgery to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the surgery.
Provide coordination and navigation for people, especially vulnerable patients or those with complex needs, and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
Engage with other healthcare providers and fill out referral forms for patient support services, such as for wheelchairs, Occupational Therapy or Care Farms for example.
Identify unpaid carers and help them access services to support them
Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances
Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Actively participate in multidisciplinary team meetings within the surgery where appropriate.
Any other duties that the practice feels are necessary
LCS/QOF/ Recalls
Be involved in LCS/ QOF/ Recalls/ searches as required (e.g. proactive healthcare and inclusion LCS)
Inclusion Health non-clinical Champion
Other Duties specific to Cutlers Hill Surgery Care Co Team
Memory screening & Referral to memory clinic
ADHD Screening & referral
ASD Screening & referral
Learning disabilities Annual review
Dementia care plans
Referral to dementia support services
Wellbeing check ins vulnerable patients
Applying for Attendance allowance
School refusals / liaising with school to support child
Attending MDT Meetings when required
Proactive health care plans
Care needs/ support needs discussions Onwards referral to social care If needed.
Applying for blue badge
Applying for Attendance allowance, carers allowance or PIP
Supporting patients completing forms
Signposting to weight management services
Signposting to disabilities advice service
Signposting for financial support services/ benefits
Signposting/referral for Isolation and befriending
Sign posting to domestic abuse services
Support with housing issues
Signposting to food bank/ community larder
Job Description
Job responsibilities
Responsibilities
Enhance inclusivity by improving access to difficult to contact patients, such as the homeless and those who cannot get transport.
Following up low tier mental health disorders and supporting the mental health clinicians.
Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Act as safeguarding administrator working closely with the Doctors, health visitors and school nurse to organising quarterly safeguarding meetings, take minutes and support actions that need to take place.
Support reception with Care Navigation and be available to the Same Day Team for support.
Support patient care between internal departments and external services to navigate them through the care system.
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.
Work collaboratively with GPs and other primary care professionals within the surgery to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the surgery.
Provide coordination and navigation for people, especially vulnerable patients or those with complex needs, and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
Engage with other healthcare providers and fill out referral forms for patient support services, such as for wheelchairs, Occupational Therapy or Care Farms for example.
Identify unpaid carers and help them access services to support them
Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances
Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
Actively participate in multidisciplinary team meetings within the surgery where appropriate.
Any other duties that the practice feels are necessary
LCS/QOF/ Recalls
Be involved in LCS/ QOF/ Recalls/ searches as required (e.g. proactive healthcare and inclusion LCS)
Inclusion Health non-clinical Champion
Other Duties specific to Cutlers Hill Surgery Care Co Team
Memory screening & Referral to memory clinic
ADHD Screening & referral
ASD Screening & referral
Learning disabilities Annual review
Dementia care plans
Referral to dementia support services
Wellbeing check ins vulnerable patients
Applying for Attendance allowance
School refusals / liaising with school to support child
Attending MDT Meetings when required
Proactive health care plans
Care needs/ support needs discussions Onwards referral to social care If needed.
Applying for blue badge
Applying for Attendance allowance, carers allowance or PIP
Supporting patients completing forms
Signposting to weight management services
Signposting to disabilities advice service
Signposting for financial support services/ benefits
Signposting/referral for Isolation and befriending
Sign posting to domestic abuse services
Support with housing issues
Signposting to food bank/ community larder
Person Specification
Experience
Essential
* Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (desirable)
* Experience in use of databases
* Experience of administrative duties
* Able to demonstrate a clear understanding of working with
* confidential information and an understanding of service user
* confidentiality
* Working in a multi-disciplinary setting where influence and
* negotiation is required
* Knowledge/familiarity with medical terminology
* Working in a busy and demanding environment whilst
* delivering in a timely manner
* Understanding of current issues facing the NHS (desirable)
* Understanding of health and social care processes (desirable)
Qualifications
Essential
* GCSEs/Diploma/ HNC level (or relevant experience)
* ECDL or equivalent
* NVQ Level 3 Business Administration (or relevant experience)
* Ongoing internal and external training to keep up to date with changes/ developments
Person Specification
Essential
* GCSEs/Diploma/ HNC level (or relevant experience)
* ECDL or equivalent
* NVQ Level 3 Business Administration (or relevant experience)
* Ongoing internal and external training to keep up to date with changes/ developments
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
Employer name
South Waveney Alliance Primary Care Network
Address
Cutlers Hill Surgery
Bungay Road
Halesworth
Suffolk
IP19 8SG
Employer details
Employer name
South Waveney Alliance Primary Care Network
Address
Cutlers Hill Surgery
Bungay Road
Halesworth
Suffolk
IP19 8SG
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