PCN MDT and Integrated Care CoordinatorNHS

Job summary

About the Role

South one PCN Newham is seeking a highly organised and motivated individual to join our team as an MDT coordinator, care coordinator and integrated care lead

This is an exciting opportunity to play a key role in delivering proactive, integrated care for patients with long term conditions (LTCs). You will lead on coordinating Multi-Disciplinary Team (MDT) working and ensuring effective clinical care coordination across services, helping improve patient outcomes and reduce health inequalities.

You will work closely with GP practices, community services, social care, and voluntary sector partners to ensure care is joined-up, person-centred and proactive, in line with the LTC Proactive Care Quality and Outcome Framework (QOF).

Main duties of the job

Key responsibilities

• Alternate and support effective MDT meetings across South One PCN, ensuring they are well structured, outcome focused, and aligned with QOF requirements.
• Provide clinical coordination for patients with complex, long-term conditions, ensuring timely follow-up and continuity of care.
• Act as a central link between primary care, community services, social care, and voluntary organisations.
• Support identification and proactive management of patients with high levels of need.
• Ensure personalised care plans are developed, implemented, and reviewed.
• Promote integrated, person-centred care that addresses physical, mental, and social needs.
• Contribute to reducing health inequalities and improving access for undeserved populations.
• Monitor MDT activity and contribute to quality improvement and performance reporting
• Support delivery and assurance of LTC Proactive care QOF requirements.

We are looking for someone who:

• Has experience in MDT coordination and/or clinical care coordination within the NHS, primary care, or community services.
• Has a strong understanding of long-term condition management and integrated care
• Is highly organised, proactive, and able to manage complex patient pathways.
• Has excellent communication and stakeholder engagement skills
• Can work effectively across organisational and professional boundaries.
• Is committed to improving patient outcomes and reducing health inequalities.

Job description

Role Purpose

The MDT Coordination, Clinical Care Coordination and Integrated Care Manager will support South One PCN to deliver high quality, proactive, and integrated care for patients with long-term conditions (LTCs).

The postholder will:

• Coordinate and optimise Multi-Disciplinary Team (MDT) working
• Provide clinical care coordination across pathways

The role ensures effective delivery of the LTC Proactive Care and Quality and Outcomes Framework (QOF) through jointed-up, person-centred, and data-informed care, improving outcomes and reducing health inequalities.

Key Duties and Responsibilities (LTC Proactive Care QOF Aligned)

MDT Coordination and Delivery

• Coordinate and support regular, structured MDT meetings for South One PCN, ensuring alignment with LTC Proactive Care QOF requirements.
• Organise MDTs at practice, neighbourhood, PCN, RPN or Borough levels as locally determined.
• Ensure MDT meetings are focused on high-need patients and result in clear actions, ownership, and follow-up.
• Maintain consistent MDT processes, agendas, case selection, documentation, and tracking outcomes.

Clinical Care Coordination

• Coordinate care for patients discussed within MDTs, ensuring timely follow-up of agreed actions and interventions.
• Act as a central point of coordination between primary care community services, social care, and voluntary sector partners.
• Support navigation of patients through complex care pathways, improving continuity and reducing fragmentation of care.
• Ensure personalised care plans or implemented, reviewed, and updated in collaboration with MDT members.
• Identify gaps in care and escalate concerns appropriately to clinical leads.
• Supports proactive management of patients at risk of deterioration, admission, or poor outcomes.

Identification and Proactive Management of LTC Patients

• Support identification and prioritisation of patients with multiple LTCs, frailty, or high risk.
• Ensure MDT discussions focus on high-risk and complex cohorts in line with QOF indicators.
• Facilitate development and review of proactive, personalised care plans

Person-Centred and Integrated Care

• Enable MDTs to deliver holistic, person-centred care planning covering physical, mental, and social needs.
• Promote shared decision making and continuity of care.
• Ensure MDT actions translate into coordinated and effective care delivery across South One PCN.

Effective MDT Working and Professional Collaboration

• Facilitate collaboration between primary care, community services, social care, and voluntary sector organisations.
• Ensure appropriate professional representation within MDTs .
• Promote Integrated ways of working to reduce duplication and improve patient experience.

Health Inequalities and Targeted Support

• Ensure MDT And care coordination activity targets patients with health inequalities or barriers to access.
• Support production of on warranted variation across the South one PCN population.
• Align work with prevention, early intervention, and neighbourhood priorities.

Quality, Outcomes and Continuous Improvement

• Monitor MDT activity and care coordination effectively against LTC proactive care quote indicators.
• Support collection of evidence demonstrating improvement in patient outcomes and service delivery.
• Use data, feedback column and learning to drive continuous improvement.

Governance, Reporting and Assurance

• Support delivery assurance for the LTC Proactive Care QOF within South One PCN.
• Provide reporting to PCN leadership, RPN, and ICB.
• Act as a key point of contact for MDT and care coordination-related performance matters.

About us

Why join us?

• Be part of a forward-thinking PCN delivering innovative, proactive care models.
• Work within a supportive, collaborative neighbourhood team.
• Play a key role in shaping integrated care services locally.
• Opportunity to make a real difference to patients with complex needs.