Patient Care Coordinator-OPD Medical

The Patient Care Coordinator serves as the patient’s named clinical key worker throughout the care pathway, from receipt of referral through treatment, follow-up, survivorship, or transition to palliative and supportive care. The role provides specialist nursing assessment, care coordination, patient and family education, symptom and risk screening, clinical triage, proactive follow-up, and timely escalation in collaboration with the responsible consultant, multidisciplinary team, and relevant support services.

The Patient Care Coordinator coordinates the patient’s end-to-end clinical pathway and works across organizational and professional boundaries to promote continuity, safety, and timely access to care. The role maintains regular contact with the patient and family, coordinates investigations and appointments, reviews outstanding actions, supports shared decision-making, and ensures that changes in clinical status or pathway delays are communicated promptly to the accountable clinical team.

Acting as the primary liaison for patients and families, the Care Coordinator facilitates access to a wide range of support services, including Finance and Insurance, Socio - Psycho and Counselling, Social Work, Nutrition, Rehabilitation, Palliative Care, and other allied health services as appropriate. The role ensures that patients and caregivers are not required to navigate complex healthcare processes independently and receive timely guidance, reassurance, and support.

The Patient Care Coordinator is a registered nursing role with responsibility for specialist assessment, care planning, clinical triage, symptom and toxicity screening within competence, patient education, care coordination, and escalation. Diagnosis, prescribing, and medical treatment decisions remain with the responsible medical practitioner and authorized multidisciplinary team members. The postholder practices within professional scope, approved competencies, organizational policies, and applicable regulatory requirements, and escalates any deterioration, safeguarding concern, complex symptom, or uncertainty without delay.

The role contributes to delivering a personalized, coordinated, and compassionate care experience that improves patient satisfaction, enhances access to supportive services, minimizes delays in care, and supports the achievement of organizational quality and patient experience objectives.
The role directly supports the performance of the institute’s and flagship program and the achievement of institute-level and executive performance commitments, through the KPIs and pathway data it owns. 

Responsibilities

•    Adheres to the approved standards of specialist nursing practice, clinical pathway coordination, and professional performance within the department, assigned clinical service, and relevant multidisciplinary partnerships.
•    Collects comprehensive data pertinent to the issues, situation, or trends related to the assigned pathway (e.g., referral volumes, appointment access, time-to-treatment).
•    Analyzes assessment data to determine the issues, problems, or trends impacting pathway performance, in line with CMSAs emphasis on comprehensive assessment as the basis for a coordinated plan of care.
•    Identifies expected outcomes for a plan individualized to the patients situation, reflecting person-centered, whole-person coordination principles.
•    Develops a plan that prescribes effective strategies and alternative(s) to attain expected outcomes, in partnership with the patient, family/caregiver, and the multidisciplinary team.
•    Implements the identified plan: coordinates the implementation and associated processes; employs strategies to foster pathway efficiency, staff development, and process improvement.
•    Provides consultation to influence the identified plan, enhance the abilities of others, and effect change.
•    Evaluates progress towards attainment of outcomes and adjusts the plan as needed in discussion with clinical and operational leadership.
•    Enhances the quality and effectiveness of clinical operations, access management, and support services delivery in a systematic manner: evaluates the operating environment and quality of service rendered.
•    Attains knowledge and competency that reflects current practice: uses current data and industry best practices (e.g., NHS Personalised Care, CMSA, patient navigation standards) to enhance role performance and increase knowledge of professional issues.
•    Evaluates own practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
•    Interacts with and contributes to the professional development of peers and colleagues.
•    Collaborates with all levels of clinical, medical, and administrative staff, interdisciplinary teams, executive leaders, and other stakeholders.
•    Integrates ethical provisions, including diversity, equity, inclusion, and belonging principles, in all areas of practice, consistent with CMSAs Standard on equitable, culturally competent care.
•    Integrates data and performance insights into practice: creates a supportive environment with sufficient resources for continuous improvement and operational excellence.
•    Maintains and demonstrates current knowledge in the administration of healthcare coordination to advance service delivery and the provision of quality healthcare services.
•    Professional Development: seeks experience to advance skills and knowledge in operations management, changes in healthcare systems, application of emerging technologies (including data analytics and AI), and innovative practice.
•    Communication: utilizes behaviors and skills which promote positive and professional communication within the work group and with patients/families.
•    Leadership: demonstrates forward-thinking leadership skills such as being a role model and mentor, a visionary and a planner, and a big-picture thinker who can enlist the voluntary support of others in building a joint future.
•    Management: demonstrates responsibility for the oversight of work processes, including analytical, financial, and work-coordination skills, judgment in decision-making, and service orientation.
•    Operations: provides specialized services that contribute to the operational success of the pathway/unit, including commitment to task, time management, prioritization, and follow-through to closure.
•    Community Resources: maintains current knowledge of internal and external community, charitable, and support resources (e.g., transport assistance, accommodation, patient support groups) and refers patients and families accordingly
•    Patient Empowerment: coaches and equips patients and families to build their own capacity to navigate the health system, ask informed questions, and participate actively in decisions, 
•    Barriers to Care / Health Disparities: proactively identifies logistical, financial, cultural, linguistic, or health-literacy barriers to care for each patient and documents and addresses them or escalates for resolution, per the GW Cancer Institute Barriers to Care/Health Disparities domain.
•    Health literacy is assessed using a standardized, brief screening instrument (e.g., Single Item Literacy Screener or Newest Vital Sign) rather than informal judgment, so results are consistent and auditable across the caseload.
•    Cultural Competency: delivers culturally sensitive support tailored to the patients and familys background, beliefs, and language needs, arranging interpreter/translation services where required.
•    Outreach: supports outreach and awareness activities that improve early identification and timely entry of patients into the pathway, consistent with the GW Cancer Institute Outreach domain.
•    Undertakes holistic needs and distress screening using approved tools, interprets findings within professional competence, initiates appropriate nursing interventions, and coordinates referral to psychology, social work, palliative care, safeguarding, or other specialist services. Urgent risks are escalated immediately in accordance with policy.
Clinical Governance: practices in accordance with the professional code, scope of practice, approved clinical competencies, medicines management requirements, safeguarding procedures, infection prevention standards, consent requirements, and organizational clinical governance policies. Maintains contemporaneous clinical records, participates in incident review, audit, supervision, and quality improvement, and acts promptly on identified patient-safety risks.

Accountabilities

•    Accountable for achievement of the clinical pathway and navigation key performance indicators assigned to the role, including time to first contact, time to assessment, time to treatment, referral completion, resolution of barriers to care, unplanned admissions where applicable, patient-reported outcomes and experience measures, and no-show rate. Reports performance against agreed targets and implements corrective action with clinical and operational leadership when standards are not met.
•    Accountable for the timely, complete, and accurate submission of pathway data used in flagship programme reporting, executive dashboards, and senior leadership performance reviews. Identifies and corrects data-quality issues promptly and escalates any risk to the accuracy, completeness, or timeliness of institutional reporting.
•    Participates as a member of the pathway/programme team, assisting in the implementation of plans, projects, and programmes to meet critical success factors of the service and the organization.
•    Ensures that relevant clinical and operational leads receive appropriate and timely information necessary to fulfil the organizations strategic and operational plans.
•    Maintains an active caseload within agreed capacity, acuity, and complexity limits, with clear arrangements for prioritisation, allocation, handover, and leave cover. Escalates capacity or safety concerns to the nursing and operational leads before continuity of care is compromised.

Responsibilities

1.    Receiving the Patient
•    On receipt of referral, completes and documents an initial holistic nursing assessment, including presenting concerns, symptoms, comorbidities, medicines where relevant, functional status, psychosocial needs, safeguarding risks, communication requirements, health literacy, and practical barriers to care. Identifies red flags, initiates action within approved pathways, and escalates urgently to the responsible clinician when required.
•    Conducts an initial orientation call/meeting to introduce the care journey, confirm contact details and preferred communication channel, and identify any immediate access barriers (language, mobility, insurance, transport).
•    Assigns and communicates the patients named Care Coordinator and single point of contact details for the remainder of the pathway.
2.    Patient & Family Education
•    Provides structured education on the pathway: what will happen, in what order, and what each appointment involves, using patient-friendly language and materials.
•    Provides and reinforces evidence-based information about the diagnosis, investigations, treatment options, expected side effects, self-management, and available support, within professional competence and the agreed plan of care. Assesses understanding, applies teach-back, corrects misconceptions, and refers questions outside scope to the appropriate clinician.
•    Provides orientation on practical matters raised across the pathway (e.g., what to bring to appointments, fasting/prep instructions, expected visit duration, wig/prosthesis information, travel considerations), escalating clinical questions to the appropriate clinician.
3.    Communication Throughout the Pathway
•    Maintains proactive, regular communication with the patient and family at each pathway milestone (results ready, MDT outcome, next steps), rather than waiting to be contacted.
•    Communicates next steps to the patient in coordination with the treating physician.
•    Provides a clearly communicated, accessible contact route for patients and families during agreed service hours, with defined cover, handover, out-of-hours advice, and emergency escalation arrangements. Ensures contacts and actions are documented in the approved clinical record.
4.    Scheduling & Sequencing Appointments
•    Coordinates the sequencing and confirmation of appointments across relevant specialties and diagnostics, working with access and scheduling teams to minimise unnecessary hospital visits and avoid conflicting appointment times. Escalates booking barriers and delays that may compromise the agreed pathway standard.
•    Proactively tracks and follows up on overdue or at-risk appointments, referrals, and results to prevent delays in the pathway.
•    Coordinates logistics for multidisciplinary reviews and communicates outcomes and next appointments promptly to the patient.
5.    Connecting the Patient with Relevant Departments
•    Identifies patient and family needs beyond the core clinical pathway and actively connects them with the relevant service, rather than only providing a referral number, including:
o    Finance/Insurance: connects patients with the finance/insurance team for cost estimates, insurance approvals, payment plans, or financial assistance programmes.
o    Psychology: coordinates a supported referral to psychology or counselling services for patients or family members with identified distress, anxiety, coping difficulties, or other psychosocial needs, and confirms that the receiving service has accepted or actioned the referral.
o    Social Work & Family Support: connects patients and families with social work for practical, housing, transport, or caregiver support needs.
o    Nutrition, Genetics, Survivorship, and other allied services: coordinates timely referral and appointment access as identified by the MDT or requested by the patient.
6.    Answering Patient & Family Queries
•    Serves as the first point of call for day-to-day patient and family queries (appointment changes, results status, process questions, general concerns).
•    Assesses patient and family queries using approved clinical triage and escalation pathways. Provides nursing advice within competence, documents the assessment and action taken, gives clear safety-netting instructions, and escalates urgent symptoms, treatment toxicities, deterioration, safeguarding concerns, or matters outside scope to the responsible clinician or emergency service without delay.
•    Closes the loop with the patient/family on every query raised, confirming resolution or next steps.
7.    Ongoing Family Support
•    Provides continuity of contact and reassurance to family members/caregivers throughout diagnosis, treatment, and follow-up, consistent with the UK key worker principle of supporting patient and family together.
•    Keeps family/caregivers informed of practical next steps and available support resources at each stage of the journey, with the patients consent.
•    Identifies caregiver strain or support needs and connects families with social work, psychology, or community/charity resources as appropriate.
8.    Supporting the Clinic Visit & Consultation
•    Prepares for each clinic/consultation in advance: confirms the patients results, prior notes, and outstanding actions are available to the physician before the visit, and flags any unresolved issues (e.g., pending tests, unmet referrals) ahead of time.
•    Supports patient flow on clinic day: confirms the patient has checked in, monitors wait time, and keeps the patient and family informed of any delay, coordinating with front-desk and nursing staff to keep the clinic session running smoothly.
•    Where clinically appropriate and with the patient’s consent, participates in consultations to provide specialist nursing input, assess understanding and support needs, reinforce agreed information, document nursing actions, and coordinate the resulting care plan. The postholder does not independently alter the medical plan unless authorized within an approved protocol or advanced scope of practice.
•    Following the consultation, confirms the patient’s understanding of the agreed plan, medicines and treatment instructions where applicable, expected symptoms and side effects, warning signs, contact routes, and follow-up arrangements. Identifies unresolved clinical or psychosocial needs and escalates them to the appropriate member of the multidisciplinary team.
•    Before the patient leaves the clinic, confirms and books the next steps arising from the consultation (follow-up appointment, tests, referrals, MDT listing) so the patient does not leave without a clear plan.
•    Feeds back clinic-day issues (delays, resource gaps, recurring patient concerns) to the Operations Director/clinic lead to support continuous improvement of the clinic experience
9.    Pathway Oversight & Continuity
•    Maintains accurate patient tracking tools/registries to monitor pathway status, referral completion, and outstanding actions across every stage above.
•    Collaborates with Case Management, Access Management, and other pathway coordinators to ensure no gap in ownership as the patient moves between departments.
•    Supports data collection and reporting on pathway and experience metrics (e.g., time-to-first-contact, time-to-appointment, query resolution time) for leadership review.
•    Updates the approved clinical record and pathway tracker on the same working day following every patient contact and significant milestone. Documentation includes assessment findings, education and advice provided, symptoms and risks identified, escalation and safety-netting actions, referrals, appointments, multidisciplinary decisions, barriers to care, patient and family queries, treatment milestones, outcomes, and follow-up arrangements.
•    Records standard navigation metrics for pathway and program reporting, aligned to the AONN+/American Cancer Society Navigation Metrics Toolkit, including: time-to-first-contact, time-to-appointment, time-to-treatment, referral completion rate, barriers identified and resolved, and no-show/missed-appointment rate.
•    Administers or coordinates administration of a navigation-specific patient experience/satisfaction survey at defined pathway milestones and reports results as part of program evaluation — separate from general facility patient-experience surveys.
•    Uses the Tracker (and hospital information system, e.g., Cerner, where integrated) to identify patients at risk of delay or drop-off and escalates proactively to the clinical or operational lead.
•    Submits a summary Tracker extract to the Operations Director / Divisional lead on the agreed reporting cycle (e.g., weekly/monthly) to support pathway performance review and leadership reporting.
 

Qualifications

Educational Qualification:
Required:
●    Bachelor’s Degree in Nursing or an equivalent recognised nursing qualification, with current registration and licence to practise as a registered nurse in the relevant jurisdiction.
Desired:
●    Postgraduate qualification or accredited specialist education relevant to the assigned clinical pathway, such as cancer nursing, advanced assessment, clinical decision-making, symptom management, palliative and supportive care, or an equivalent field.
●    Relevant accredited training in care coordination, personalised care, patient navigation, or case management, supported by evidence of continuing professional development in the assigned clinical specialty.
●    Certified Case Manager (CCM) credential from the Commission for Case Manager Certification (CCMC), or equivalent case management/patient navigation certification.
 

Experience:
Required:
●    Minimum five years of post-registration nursing experience, including at least two years in the relevant specialty or an equivalent complex care pathway. Demonstrated experience in holistic assessment, clinical triage, patient education, multidisciplinary working, care coordination, escalation, and management of an active caseload is required.
Desired:
●    Experience in a specialty care pathway coordination role, or experience within a multidisciplinary/tumor board or similar case-conference coordination process.