Job summary

We are looking to expand our Care Co-ordinators team, you will be responsible for supporting the practice in delivering excellent patient care by effectively co-ordinating different elements of care from multi-disciplinary teams within the practice.

The post holder will be the first point of contact for patients and relatives in case their needs change. Many patients have complex highly complex needs and would need support in coordinating with relevant services. The Care coordinator will support the patient with their needs and find the relevant services.

Main duties of the job

Utilise both internal and external population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

To undertake Personalised Care Training commensurate with the role.

Support patients to utilise decision aids in preparation for a shared decision-making conversation.

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 (PCSP).

Help patients 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.

Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

Co-ordinate the delivery of the Multi-Disciplinary Team Meetings within the Practice, Care Homes and external providers.

Build and maintain effective professional relationships with the MDT and create a network of contacts to assist the MDT in providing the most effective package of patient care.

Schedule and organise MDT meetings, liaising with key members of the team. Manage all administrative duties to include preparation and distribution of agenda items and the taking and distributing of meeting minutes and action plans.

About us

Bridge Surgery is a very friendly, supportive, well organised GMS training practice with:

• 10,000 patients
• 4 Partners, 3 Salaried GPs and GP Trainees
• SystmOne
• High QOF achievement
• CQC good in all areas

Details

Date posted

13 October 2026

Pay scheme

Other

Salary

£13.01 an hour

Contract

Permanent

Working pattern

Part-time

Reference number

A1408-26-0006

Job locations

St Peters Street

Stapenhill

Burton on Trent

Staffordshire

DE15 9AW

United Kingdom

Job description

Job responsibilities

The following are the core responsibilities of the role. There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:

Utilise both internal and external population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

To undertake Personalised Care Training commensurate with the role.

Support patients to utilise decision aids in preparation for a shared decision-making conversation.

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 (PCSP).

Help patients 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.

Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

Co-ordinate the delivery of the Multi-Disciplinary Team Meetings within the Practice, Care Homes and external providers.

Work with the GPs and other primary care professionals to identify and manage a caseload of patients and where required/appropriate, refer patients onto to other health professionals.

Build and maintain effective professional relationships with the MDT and create a network of contacts to assist the MDT in providing the most effective package of patient care.

Schedule and organise MDT meetings, liaising with key members of the team. Manage all administrative duties to include preparation and distribution of agenda items and the taking and distributing of meeting minutes and action plans.

Take responsibility for co-ordinating the actions arising from the meetings ensuring that this is carried out in a timely, effective and coherent manner.

Ensure that all patients Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensuring relevant information is available.

Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with the primary care team.

Act as a conduit between the Practice Clinical Team and the external Care Homes, providing first line support and guidance and ensuring an effective and efficient package of support is provided to our Care Homes patients. This includes ringing the care homes on a weekly basis.

Assist in the identification of housebound patients, work with the primary care team and social prescriber to ensure that the package of care provided to this cohort suits the individual needs of the patient.

Support with QOF outputs for the year and any other areas within PCN.

Maintain the various long term condition registers, update as necessary and send the associated recall letters.

Maintain the cervical cytology system, check routine cytology recall lists, input results and send appropriate recall and referral letters.

Send reminder, invitation and ad-hoc letters to patients as required/appropriate.

Construct and maintain templates in conjunction with clinical staff.

Monitor and action all e-mails sent to the generic surgery e-mail account throughout the day as per our protocol.

Carrying out searches and interrogating the system to provide necessary audits and reports, on both a periodic and ad hoc basis as required by the management and clinical teams.

Read coding of information into the practice clinical system consistently, accurately and in a timely manner to ensure safe practice as required.

Check GP pathology results each morning, matching unmatched patient results and allocating any unallocated results. Share out the results of GPs not on duty that day.

To drive wellbeing within the practice with Staff and patients.

Other duties as agreed with the Partnership.

This Job Description is not exhaustive and duties may vary from time to time dependent upon the requirements of the business.

Job description Job responsibilities The following are the core responsibilities of the role. There may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels: Utilise both internal and external population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. To undertake Personalised Care Training commensurate with the role. Support patients to utilise decision aids in preparation for a shared decision-making conversation. 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 (PCSP). Help patients 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. Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level. Co-ordinate the delivery of the Multi-Disciplinary Team Meetings within the Practice, Care Homes and external providers. Work with the GPs and other primary care professionals to identify and manage a caseload of patients and where required/appropriate, refer patients onto to other health professionals. Build and maintain effective professional relationships with the MDT and create a network of contacts to assist the MDT in providing the most effective package of patient care. Schedule and organise MDT meetings, liaising with key members of the team. Manage all administrative duties to include preparation and distribution of agenda items and the taking and distributing of meeting minutes and action plans. Take responsibility for co-ordinating the actions arising from the meetings ensuring that this is carried out in a timely, effective and coherent manner. Ensure that all patients Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensuring relevant information is available. Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with the primary care team. Act as a conduit between the Practice Clinical Team and the external Care Homes, providing first line support and guidance and ensuring an effective and efficient package of support is provided to our Care Homes patients. This includes ringing the care homes on a weekly basis. Assist in the identification of housebound patients, work with the primary care team and social prescriber to ensure that the package of care provided to this cohort suits the individual needs of the patient. Support with QOF outputs for the year and any other areas within PCN. Maintain the various long term condition registers, update as necessary and send the associated recall letters. Maintain the cervical cytology system, check routine cytology recall lists, input results and send appropriate recall and referral letters. Send reminder, invitation and ad-hoc letters to patients as required/appropriate. Construct and maintain templates in conjunction with clinical staff. Monitor and action all e-mails sent to the generic surgery e-mail account throughout the day as per our protocol. Carrying out searches and interrogating the system to provide necessary audits and reports, on both a periodic and ad hoc basis as required by the management and clinical teams. Read coding of information into the practice clinical system consistently, accurately and in a timely manner to ensure safe practice as required. Check GP pathology results each morning, matching unmatched patient results and allocating any unallocated results. Share out the results of GPs not on duty that day. To drive wellbeing within the practice with Staff and patients. Other duties as agreed with the Partnership. This Job Description is not exhaustive and duties may vary from time to time dependent upon the requirements of the business.

Person Specification

Experience

Essential

• Experience of Microsoft Office packages e.g. PowerPoint, Word, Excel and other IT skills acquired through training or practical skills

Desirable

• Working in Primary Care

Person Specification Experience Essential Experience of Microsoft Office packages e.g. PowerPoint, Word, Excel and other IT skills acquired through training or practical skills Desirable Working in Primary Care

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

Bridge Surgery

Address

St Peters Street

Stapenhill

Burton on Trent

Staffordshire

DE15 9AW

United Kingdom

Employer's website

https://www.bridgesurgery.net/ (Opens in a new tab)

Employer details

Employer name

Bridge Surgery

Address

St Peters Street

Stapenhill

Burton on Trent

Staffordshire

DE15 9AW

United Kingdom

Employer's website

https://www.bridgesurgery.net/ (Opens in a new tab)