Care Coordinator (Proactive Neighbourhood Care & Remote MonitoringNHS

Job summary

The Proactive Neighbourhood Care and Remote Monitoring service will support people living with frailty, complex needs and those who are housebound. The service will combine proactive home visiting, care coordination, remote monitoring and links into wider neighbourhood and Local Authority support.

The Care Coordinator will be central to the day-to-day organisation of the service. The postholder will coordinate referrals, appointments, visits and actions, maintain oversight of the caseload and act as a key link between patients, practices, clinicians and partner organisations.

Main duties of the job

• Receive and process referrals, check information and ensure patients are added to the correct pathway.
• Contact patients and carers, explain the service and arrange assessments, visits and follow-up.
• Maintain accurate caseload and action trackers and make sure outstanding actions are followed through.
• Coordinate clinician and driver schedules and support efficient use of available capacity.
• Liaise with GP practices, Local Authority teams, community services and other partners.
• Support remote monitoring onboarding and follow-up alongside the HCA and clinical team.
• Enter and update information accurately on EMIS, spreadsheets and other service systems.
• Support activity, outcome and performance reporting and identify gaps or delays to the Service Manager.
• Handle patient information sensitively and escalate clinical or safeguarding concerns promptly.

Job description

• Receive and process referrals, check information and ensure patients are added to the correct pathway.
• Contact patients and carers, explain the service and arrange assessments, visits and follow-up.
• Maintain accurate caseload and action trackers and make sure outstanding actions are followed through.
• Coordinate clinician and driver schedules and support efficient use of available capacity.
• Liaise with GP practices, Local Authority teams, community services and other partners.
• Support remote monitoring onboarding and follow-up alongside the HCA and clinical team.
• Enter and update information accurately on EMIS, spreadsheets and other service systems.
• Support activity, outcome and performance reporting and identify gaps or delays to the Service Manager.
• Handle patient information sensitively and escalate clinical or safeguarding concerns promptly.

About us

The Primary Care Alliance (PCA) is the collaborative voice of general practice across the Berkshire West Place within the Thames Valley Integrated Care System. We bring together GP practices and Primary Care Networks (PCNs) to work at scale, enabling innovation, influencing system change, and delivering services that meet the needs of our local populations.

PCA plays a vital role in shaping the future of primary care by strengthening partnerships, developing the workforce, and ensuring general practice is a central and equal partner in integrated care. As a community interest company, PCA supports primary care sustainability, equity, and improved outcomes for patients across Reading, Wokingham, and West Berkshire.