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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 CMSA's emphasis on comprehensive assessment as the basis for a coordinated plan of care.
• Identifies expected outcomes for a plan individualized to the patient's 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 CMSA's 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 patient's and family's 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.

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.

Additional Requirements:

Required:

• Specialist clinical knowledge of the assigned pathway, including common presentations, investigations, treatments, treatment-related risks, symptom assessment, deterioration, psychosocial needs, safeguarding, rehabilitation, survivorship, and palliative and supportive care. Applies this knowledge safely within professional scope and approved competencies.
• Demonstrated ability to support patients through their end-to-end care journey, providing guidance, reassurance, and continuity from referral through follow-up.
• Ability to deliver clear, empathetic patient and family education tailored to individual understanding and needs throughout the care pathway.
• Strong understanding of patient pathway coordination and multidisciplinary care models, consistent with CMSA and NHS care coordination frameworks.
• Excellent communication and interpersonal skills for liaising with patients, families, and multidisciplinary teams.
• Proficiency with hospital information systems (e.g., Cerner) for scheduling, tracking, and documentation.
• Strong organizational skills with the ability to manage multiple patient cases simultaneously.
• Data tracking and reporting skills to support pathway performance monitoring.