Patient Care Coordinator-Operations Management

Role Overview

Patient Care Coordinator-Operations Management at Sheikh Shakhbout Medical City (SSMC). 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.

Role Purpose

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 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 flagship program and the achievement of institute-level and executive performance commitments through the KPIs and pathway data it owns.

Key Responsibilities

Clinical Assessment and Care Planning

• Conduct specialist nursing assessment, holistic needs screening, and distress screening using approved tools.
• Develop individualized care plans that prescribe effective strategies and alternatives to attain expected outcomes, in partnership with the patient, family/caregiver, and the multidisciplinary team.
• Identify expected outcomes for a plan reflecting person-centered, whole-person coordination principles.
• Interpret screening findings within professional competence and initiate appropriate nursing interventions.
• Coordinate referral to psychology, social work, palliative care, safeguarding, or other specialist services.
• Escalate urgent risks immediately in accordance with policy.

Patient and Family Support

• Maintain regular contact with the patient and family throughout the care pathway.
• Facilitate 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.
• Act as the primary liaison for patients and families, ensuring they are not required to navigate complex healthcare processes independently.
• Provide timely guidance, reassurance, and support to patients and caregivers.
• Deliver clear, empathetic patient and family education tailored to individual understanding and needs throughout the care pathway.
• Support patients through their end-to-end care journey, providing guidance, reassurance, and continuity from referral through follow-up.

Patient Empowerment and Health Literacy

• Coach and equip patients and families to build their own capacity to navigate the health system, ask informed questions, and participate actively in decisions.
• Assess health literacy using a standardized, brief screening instrument such as the Single Item Literacy Screener or Newest Vital Sign, rather than informal judgment, to ensure results are consistent and auditable across the caseload.
• Deliver culturally sensitive support tailored to the patient's and family's background, beliefs, and language needs.
• Arrange interpreter and translation services where required.

Barriers to Care and Health Disparities

• Proactively identify logistical, financial, cultural, linguistic, or health-literacy barriers to care for each patient.
• Document and address barriers or escalate for resolution, per the GW Cancer Institute Barriers to Care/Health Disparities domain.
• Integrate ethical provisions, including diversity, equity, inclusion, and belonging principles, in all areas of practice, consistent with CMSA's Standard on equitable, culturally competent care.

Care Pathway Coordination

• Coordinate the patient's end-to-end clinical pathway and work across organizational and professional boundaries to promote continuity, safety, and timely access to care.
• Coordinate investigations and appointments.
• Review outstanding actions.
• Support shared decision-making.
• Ensure that changes in clinical status or pathway delays are communicated promptly to the accountable clinical team.
• Implement the identified care plan, coordinate associated processes, and employ strategies to foster pathway efficiency, staff development, and process improvement.

Clinical Triage and Symptom Management

• Perform clinical triage, symptom and toxicity screening within competence.
• Recognize common presentations, investigations, treatments, treatment-related risks, symptom assessment, and deterioration within the assigned pathway.
• Manage psychosocial needs, safeguarding, rehabilitation, survivorship, and palliative and supportive care within professional scope.

Data Collection and Analysis

• Collect comprehensive data pertinent to issues, situations, or trends related to the assigned pathway, such as referral volumes, appointment access, and time-to-treatment.
• Analyze assessment data to determine 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.
• Track and report pathway performance data to support pathway performance monitoring.
• Integrate data and performance insights into practice to create a supportive environment with sufficient resources for continuous improvement and operational excellence.

Quality Improvement and Operations

• Enhance the quality and effectiveness of clinical operations, access management, and support services delivery in a systematic manner.
• Evaluate the operating environment and quality of service rendered.
• Evaluate progress towards attainment of outcomes and adjust the plan as needed in discussion with clinical and operational leadership.
• Provide consultation to influence the identified plan, enhance the abilities of others, and effect change.

Professional Practice and Governance

• Adhere to the approved standards of specialist nursing practice, clinical pathway coordination, and professional performance within the department, assigned clinical service, and relevant multidisciplinary partnerships.
• Practice 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.
• Maintain contemporaneous clinical records.
• Participate in incident review, audit, supervision, and quality improvement.
• Act promptly on identified patient-safety risks.
• Escalate any deterioration, safeguarding concern, complex symptom, or uncertainty without delay.

Professional Development and Knowledge

• Attain knowledge and competency that reflects current practice.
• Use current data and industry best practices, such as NHS Personalised Care, CMSA, and patient navigation standards, to enhance role performance and increase knowledge of professional issues.
• Evaluate own practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
• Interact with and contribute to the professional development of peers and colleagues.
• Seek 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.
• Maintain current knowledge in the administration of healthcare coordination to advance service delivery and provision of quality healthcare services.
• Maintain current knowledge of internal and external community, charitable, and support resources such as transport assistance, accommodation, and patient support groups, and refer patients and families accordingly.

Outreach

• Support outreach and awareness activities that improve early identification and timely entry of patients into the pathway, consistent with the GW Cancer Institute Outreach domain.

Collaboration and Leadership

• Collaborate with all levels of clinical, medical, and administrative staff, interdisciplinary teams, executive leaders, and other stakeholders.
• Demonstrate forward-thinking leadership skills such as being a role model and mentor, a visionary and planner, and a big-picture thinker who can enlist the voluntary support of others in building a joint future.
• Utilize behaviors and skills that promote positive and professional communication within the work group and with patients and families.
• Demonstrate responsibility for the oversight of work processes, including analytical, financial, and work-coordination skills, judgment in decision-making, and service orientation.
• Provide specialized services that contribute to the operational success of the pathway/unit, including commitment to task, time management, prioritization, and follow-through to closure.

Qualifications & Experience

Required Education

• 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 Education

• 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.

Required Experience

• 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.

Desired Experience

• Experience in a specialty care pathway coordination role, or experience within