Care Coordinator - Multi-Disciplinary Team

Overview

Go back South Hambleton and Ryedale Primary Care Network

The closing date is 05 October 2025

Join SHaR PCN as a Care Coordinator for our Multi-Disciplinary Team and play a pivotal role in transforming patient care across Ryedale and South Hambleton. This 22.5-hour permanent position offers the opportunity to coordinate complex care pathways, facilitate MDT meetings, and ensure seamless patient journeys through our integrated health services.

As part of our award-winning Primary Care Network\’s established Personalised Care Team, you\’ll work alongside Occupational Therapists, Health and Wellbeing Coaches, and Social Prescribing Link Workers to deliver our innovative \’Age Well\’ and \’Live Well\’ programmes. You\’ll be instrumental in bringing together multidisciplinary professionals to create personalised care plans that truly matter to patients.

You\’ll coordinate care for people with long-term conditions, mental health challenges, and complex needs whilst developing your career in a supportive, forward-thinking environment. If you\’re passionate about patient-centred care and want to make a real difference in people\\\’s lives, this role offers the perfect opportunity to grow professionally whilst contributing to our mission of making personalised care \’business as usual\’.

Main duties of the job

• Organise and manage regular multidisciplinary team (MDT) meetings ensuring all relevant information, notes and reports are available for discussion
• Facilitate weekly/fortnightly/monthly MDT meetings and disseminate outcomes to all relevant care providers and stakeholders
• Develop and review personalised care and support plans (PCSP) based on what matters most to patients
• Coordinate patient pathways through primary and secondary care services, identifying and addressing any bottlenecks or delays
• Communicate complex, sensitive information to healthcare professionals across multiple departments and agencies
• Maintain accurate, appropriately coded patient records and ensure care plans are uploaded to relevant online care systems
• Provide navigation support for patients and carers across health and care services
• Support population health initiatives by proactively identifying patients who would benefit from care coordination
• 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
• Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them
• Travel flexibly across all seven SHaR PCN practices (Pickering, Kirkbymoorside, Helmsley, Terrington, Stillington, Tollerton, and Millfield) while based from Easingwold Health Centre

About us

SHaR PCN is an award-winning Primary Care Network comprising seven GP practices, providing our communities in Ryedale and South Hambleton with responsive and effective primary care. We\\\’re proud leaders in personalised care, having established one of the region\\\’s most comprehensive Personalised Care Teams.

Our dynamic, forward-thinking approach has earned recognition for our commitment to putting patients at the heart of everything we do. We\\\’ve pioneered the \’Age Well\’ and \’Live Well\’ service streams, demonstrating our dedication to tailored care across all age groups. Our collaborative culture encourages professional development, with opportunities for training, career progression, and meaningful contribution to service improvement.

Working at SHaR means joining a supportive, multidisciplinary environment where your voice matters and your ideas drive positive change. We offer excellent professional development opportunities, comprehensive training programmes, and the chance to work with cutting-edge approaches to integrated care.

Our team ethos centres on mutual respect, continuous learning, and shared commitment to reducing health inequalities. You\\\’ll benefit from strong clinical leadership, regular supervision, and the satisfaction of making a tangible difference to patient outcomes in a close-knit, rural community setting.

Job responsibilities

About the Role

The Care Coordinator – Multi-Disciplinary Team position represents an exciting opportunity to join SHaR PCN\\\’s innovative Personalised Care Team. This permanent, 22.5-hour role is fundamental to our mission of delivering coordinated, patient-centred care across our seven GP practices in Ryedale and South Hambleton.

Key Purpose

You\\\’ll ensure patient health and care planning is timely, efficient, and genuinely patient-centred by coordinating multidisciplinary team meetings and facilitating seamless communication among healthcare professionals. Your role directly supports the NHS Long Term Plan\\\’s commitment to making personalised care standard practice throughout the health and social care system.

MDT Meeting Coordination You\\\’ll organise and manage regular multidisciplinary team meetings, ensuring all relevant patient information, clinical notes, and reports are readily available for discussion. Your meticulous attention to detail will ensure meeting outcomes are accurately documented and disseminated to all identified care providers, with treatment plans properly recorded for future reference.

Patient Pathway Management Working autonomously, you\\\’ll coordinate complex patient journeys through primary and secondary care, communicating sensitive information to diverse healthcare professionals. You\\\’ll negotiate with various departments, seek professional advice when needed, and maintain comprehensive attendance records of MDT participation.

Personalised Care Planning You\\\’ll be actively involved in introducing, developing, and reviewing personalised care and support plans (PCSP). Working holistically, you\\\’ll bring together all identified care and support needs, exploring options within a single, comprehensive plan based on what matters most to the individual patient.

Care Coordination and Navigation Providing coordination and navigation support for patients and their carers across health and care services, you\\\’ll work closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. You\\\’ll help patients manage their needs through answering queries, managing appointments, and ensuring they receive high-quality information to make informed care choices.

Quality Improvement and Development You\\\’ll identify health inequalities and provide feedback on engagement enhancement opportunities. Supporting the PCN\\\’s implementation of new care models, you\\\’ll provide regular updates and feedback, helping adapt and improve services to better meet patient needs.

Key Tasks and Competencies

Administrative Excellence Proficiency in healthcare databases and IT systems is essential for effective data management and reporting. You\\\’ll provide comprehensive administrative support to the MDT, including typing meeting minutes, following up on action points, and ensuring compliance with healthcare regulations.

Relationship Building Developing close working relationships with Personalised Care Team members, you\\\’ll negotiate with all parties involved in care issues to establish productive working relationships and improve patient journey coordination.

Communication and Documentation Your role requires exceptional verbal and written communication skills for effective collaboration with healthcare professionals and maintaining accurate patient records. You\\\’ll recognise patients\\\’ needs for alternative communication methods and respond appropriately.

Professional Development Working with a named clinical point of contact, you\\\’ll undertake continual personal and professional development, actively participating in reviewing and developing the role whilst adhering to organisational policies including confidentiality, safeguarding, information governance, and health and safety requirements.

This role operates within an integrated neighbourhood team consisting of various health and care professionals. You\\\’ll contribute to the wider PCN aims and objectives whilst maintaining flexibility and demonstrating willingness to undertake additional duties within the role\\\’s general character and responsibility level.

Impact and Outcomes

Your contribution as Care Coordinator will directly enhance existing skill mix, resulting in improved patient lives, timelier access to services, and increased patient confidence and skills in managing their own health and wellbeing. You\\\’ll address wider determinants of health including housing, debt, stress, and loneliness whilst supporting GP and staff workloads.

Location & Travel Requirements

While based at Easingwold Health Centre, you\\\’ll be required to travel flexibly across all seven of our GP practices (Pickering, Kirkbymoorside, Helmsley, Terrington, Stillington, Tollerton, and Millfield) to deliver services and support patients in their local communities. This role therefore requires a current full driving licence and sole use of your own vehicle.

Person Specification

Experience

• Experience working in health, social care and other support roles in direct contact with people, families or carers (paid or voluntary capacity)
• Experience supporting people, their families and carers in a related role
• Experience working with vulnerable people, complying with best practice and relevant legislation
• Demonstrable commitment to professional and personal development
• Proficient in MS Office and web-based services
• Direct experience working as a care coordinator in adult health and social care, learning support or public health/health improvement
• Experience working within multi professional team environments
• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure service impact

Qualifications

• NVQ Level 3 in adult care – advanced level or equivalent qualifications (or working towards)
• Enrolled in, undertaking or qualified in appropriate training as set out in the Personalised Care Institute core curriculum
• Additional healthcare-related qualifications
• Formal training in care coordination or similar roles

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 name

South Hambleton and Ryedale Primary Care Network