Community High Intensity Nurse Case Manager - Countywide

Buckinghamshire Healthcare NHS Trust; Aylesbury; On-site; GBP 49,000 - 57,000; Full time

Benefits offered by this job

Flexible working

NHS pension

Generous annual leave

NHS discount schemes

Job summary

Buckinghamshire Healthcare NHS Trust invites applications for a Community High Intensity Nurse Case Manager (Band 7) to coordinate care for high‑needs patients across community and primary care pathways.

You will undertake holistic assessments, develop personalised care plans and liaise with multidisciplinary teams to reduce avoidable attendances and admissions. This role focuses on proactive case management and improved patient experience in Buckinghamshire.

Qualifications

• Registered Adult Nurse with current NMC registration and extensive community practice.
• Community Specialist Practitioner Qualification and CPD evidence.
• Full UK driving licence and access to a vehicle.
• Experience of managing high intensity service users in community settings.

Responsibilities

• Manage a designated caseload of high intensity users with comprehensive holistic assessments.
• Develop personalised care plans addressing complex health and social care needs.
• Lead multi-agency coordination between primary care, community services, acute trusts and social care.
• Monitor patients at risk of deterioration and respond to ED attendances and hospital admissions.
• Support self-management, advance care planning and crisis/escalation planning.
• Contribute to service development, quality improvement and outcome measurement.

Skills

Long-term condition management

Frailty and multimorbidity

Safeguarding legislation and practice

Personalised care planning

Community healthcare pathways

Advanced clinical assessment skills

Care coordination and case management

Leadership and influencing skills

Problem-solving and decision-making

Autonomy and collaboration

Organisational skills

One-to-one and group teaching

Education

Registered Adult Nurse with current NMC registration

Community Specialist Practitioner Qualification

Evidence of continuing professional development

Full UK driving licence and access to a vehicle

Long term conditions module

Advanced Clinical Assessment Qualification

Teaching qualification or Practice Assessor or Mentorship Qualification

Non-Medical Prescribing Qualification

Palliative care module

Master's Degree or equivalent experience

Job description

Community High Intensity Nurse Case Manager - Countywide

Band 7

Main area Community Nursing Grade Band 7 Contract Permanent Hours

• Full time
• Part time
• Job share
• Flexible working

37.5 hours per week Job ref 434-CR8263264

Site William Rathbone House Town Aylesbury Salary £49,387 - £56,515 per annum (pro rata for part time) Salary period Yearly Closing 17/09/2026 23:59

Be part of our BHT family

Buckinghamshire Healthcare NHS Trust (BHT) is an integrated provider of acute hospital and community services for people living in Buckinghamshire and the surrounding area.

We care for over half a million patients every year:

• Provide specialist spinal services at our world renowned National Spinal Injuries Centre at Stoke Mandeville Hospital, the birthplace of the Paralympics
• Nationally recognised for urology and skin cancer services
• Regional specialist centre for burns, plastic surgery, dermatology, stroke and cardiac services
• Deliver community services in health centres, schools, patients’ own homes, community hospitals and community hubs.

More than 6,500 people from different nations, cultures and backgrounds work for us.

We would be happy to discuss possible flexible working options. We strive to be a family friendly, inclusive employer.

We pride ourselves in being a great place to work and invite you to join our BHT family.

Job overview

An exciting opportunity has arisen for a motivated and experienced Qualified District Nurse to join our Community High Intensity User Service as a Nurse Case Manager.

This innovative role focuses on supporting individuals who frequently access urgent and emergency healthcare services and often have complex physical health, frailty, mental health or social care needs. Through proactive case management, comprehensive assessment and coordinated multidisciplinary working, you will help patients achieve better health outcomes while reducing avoidable Emergency Department attendances and hospital admissions.

Working across community, primary care, acute, mental health, social care and voluntary sector services, you will develop personalised care plans that address the underlying causes of repeated healthcare use. You will build strong therapeutic relationships with patients, families and carers, supporting individuals to access the right care, at the right time, in the right place.

This is an excellent opportunity to contribute to an innovative service that improves patient experience, promotes independence and supports more effective use of healthcare resources across the Buckinghamshire healthcare system.

Main duties of the job

The postholder will manage a designated caseload of high intensity users, undertaking comprehensive holistic assessments and developing personalised care plans to address complex health and social care needs. They will act as the lead coordinator for patients requiring multi-agency input, ensuring effective communication and collaboration between primary care, community services, acute trusts, mental health services, ambulance services, social care and voluntary sector organisations.

The Community High Intensity User Nurse Case Manager will proactively monitor patients at risk of deterioration, provide timely interventions following emergency department attendances, hospital admissions or discharge, and lead multidisciplinary reviews to support coordinated care delivery. They will work closely with patients and carers to promote self-management, facilitate advance care planning and develop crisis and escalation plans that reduce avoidable admissions and emergency service use.

The postholder will also contribute to service development, quality improvement and outcome measurement, providing specialist advice, education and support to colleagues across the wider healthcare system. Through strong clinical leadership and partnership working, they will help deliver improved patient experience, enhanced health outcomes and more effective use of healthcare resources.

What does Buckinghamshire Healthcare NHS Trust offer you?

• As part of our BHT family, you’ll benefit from learning and development opportunities to support your career progression.
• We offer flexible and agile workingopportunities,alongside your NHS benefits ofgenerous annual leave entitlement, pension andaccess toNHS discount schemes.
• We provide a range of health and wellbeing services to promote a healthy, happy workforce.

Why work for us?

• We’re committed to promoting inclusion and making sure all colleagues feel they belong. We encourage new colleagues from a diverse range of backgrounds to apply.
• As an employer, we aim to create a workplace where differences are valued and colleagues treat one another with dignity and respect.
• Greater diversity withinourBHT familyimprovespositive outcomes for the people and communities we serve.
• A keen supporter of the Armed Forces Community who know the value of employing a service leaver/veteran and their families.

What do we stand for?

• Our vision is to provide outstanding care, support healthy communities and be a great place to work.
• Our mission is to provide personal and compassionate care every time.
• Our care values are collaborate, aspire, respect and enable.

Detailed job description and main responsibilities

For a comprehensive list of responsibilities and duties, please kindly refer to the Job Description and Person Specification by downloading the JD and PS attachment in the advert.

If you are an internal applicant there is the option for secondment, all applicants must have the endorsement/support of their line manager prior to application.

Person specification

2. EDUCATION, QUALIFICATIONS & TRAINING

• Registered Adult Nurse with current NMC registration.
• Community Specialist Practitioner Qualification.
• Evidence of continuing professional development.
• Full UK driving licence and access to a vehicle.
• Long term conditions module
• Advanced Clinical Assessment Qualification.
• Teaching qualification or Practice Assessor or Mentorship Qualification
• Non-Medical Prescribing Qualification.
• Palliative care module
• Master's Degree or equivalent experience

Experience

• Experience managing patients with multiple long-term conditions.
• Extensive experience working within community or integrated care services.
• Experience of complex case management in the community.
• Experience working within multidisciplinary teams.
• Experience of autonomous clinical decision making.
• Community Matron long term (conditions)/ complex case manager experience.
• Frailty management experience.
• Experience managing high intensity service users.

SKILLS, ABILITIES & KNOWLEDGE

• Long-term condition management.
• Frailty and multimorbidity.
• Safeguarding legislation and practice.
• Personalised care planning.
• Community healthcare pathways.
• Advanced clinical assessment skills.
• Care coordination and case management skills.
• Leadership and influencing skills.
• Problem-solving and decision-making abilities.
• Ability to work autonomously and collaboratively.
• Strong organisational skills.
• Able to provide one to one teaching and large group teaching
• Problem Solving and decision making

PPE requirements: Buckinghamshire Healthcare NHS Trust requires all colleagues to wear appropriate personal protective equipment (PPE) in accordance with our infection prevention and control procedures.

Flu vaccinations remain the best way to protect yourself, your family, your colleagues and of course our patients from the viruses when working in our healthcare settings. We encourage our staff to be vaccinated when recommended.

Application deadline: This post will close on the closing date stated at midnight, however if we receive a large number of applications or there is a change in circumstance, we may be required to close a job before the advertised date.

Contacting you: We will contact candidates through the email address supplied on their application form. Please make sure you check this regularly.

Application information: If you are offered a job, information will be transferred into the national NHS Electronic Staff Records (ESR) system.

Shortlisting: The monitoring and safeguarding sections are not made visible to the shortlisting panel. The safeguarding section may be made visible to the interview panel, dependent on the role being recruited into.

Travel expenses: It is Trust policy that travel expenses for interviews will not be reimbursed.

Smoking: All Trust sites are NO SMOKING. Smoking in all areas of the buildings and premises is prohibited.

Employer certification / accreditation badges

You must have appropriate UK professional registration.

This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.

Name Claire Jones Job title Lead Nurse for Community Nursing & Transformation Email address [e-mail] Telephone number 07929370499