PCN MDT and Integrated Care Coordinator

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 practises, 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).,

• Alternate and support effective MDT meetings across S 1 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.
  
  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.
  
  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.