Care Coordinator, Cardiac Department(10482)

National University Hospital; Singapore; On-site; SGD 60,000 - 90,000; Full time

Job summary

The National University Hospital in Singapore is seeking a Care Coordinator for the Transitional Shared Care Programme (TSCP) to review patient suitability and coordinate individualized care plans. You will manage follow-ups, track progress, and facilitate care transitions between tertiary and primary care, working with multidisciplinary teams.

You will monitor outcomes, maintain programme databases, support clinical audits, and contribute to quality improvement initiatives to ensure optimal

Qualifications

• At least 3 years’ working experience in healthcare settings.
• Good verbal and written communication skills.
• Strong interpersonal skills with the ability to engage and work with all levels of staff.
• Have a positive and proactive mindset.
• A good team player who is able to work independently.

Responsibilities

• Review and assess patients for suitability and eligibility for enrolment into TSCP.
• Coordinate and implement individualized follow-up plans based on clinical needs.
• Monitor patients' progress, attendance, and compliance with protocols.
• Facilitate follow-up appointments across cardiology clinics, NUP, Primary Care Networks, and General Practitioners.
• Liaise with clinicians, nurses, and allied health professionals for continuity of care.
• Track patient achievement of treatment targets and outcomes.
• Maintain patient records and databases for case management and evaluation.
• Support clinical audits and quality improvement activities.

Skills

Communication

Interpersonal skills

Proactive mindset

Team player

Education

Degree in Science or Nursing

Job description

The Care Coordinator is responsible for reviewing and assessing patients' suitability for enrolment
into the Transitional Shared Care Programme (TSCP), and for coordinating, implementing and
evaluating individualized care plans to ensure continuity of care and achievement of clinicaloutcomes. The role focuses on patient care coordination, treatment adherence, follow-up
management, patient and caregiver education, and facilitation of care transitions between tertiary
and primary care settings. The Care Coordinator collaborates closely with multidisciplinary
healthcare teams and community care partners to address barriers to care, support selfmanagement,
and optimize patients' health outcomes.In addition, the incumbent monitors patient outcomes, maintains programme databases, andsupports clinical audit and quality improvement activities.

Job Responsibilities

1. Care Coordinator RolePatient Assessment and Care Coordination, including:
   • a. Proactively identify and assess patients for suitability and eligibility for enrolment into TSCP.
   • b. Review patients' suitability with the clinician-in-charge and facilitate enrolment into the programme.
   • c. Develop and coordinate individualized follow-up plans based on patients' clinical needs.
   • d. Monitor patients' treatment progress, attendance, and compliance with clinical protocols.
   • e. Coordinate and arrange necessary follow-up appointments across cardiology clinics, NUP, Primary Care Networks, and General Practitioners.
   • f. Facilitate smooth transition of care between specialist and primary care settings.
   • g. Monitor patients' treatment progress, attendance and compliance with clinical protocols.
   • h. Follow up with patients who default appointments and implement interventions to improve compliance.
   • i. Liaise with cardiologists, nurses, allied health professionals and primary care partners to ensure continuity of care.
   • j. Track patients' achievement of treatment targets and clinical outcomes.
   • k. Maintain accurate patient records and databases for case management, outcome monitoring, and service evaluation.
   Track performance of TSCP
   • a. Create database to track all patients, who are enrolled in the programme.
   • b. Record patients’ attendances at both primary care settings and cardiology clinics.
   • c. Track and document each recruited patient’s progress and ensure compliance of the clinical protocol.
   • d. Record achievement of treatment targets for all patients.
2. 2) Clinical Audit Coordinator Role
   • - Collect AMI (acute myocardial infarction) mortality data and ensure timely submission to MOH- Prepare reports and timely submission to the HOD (Head of Department) and Medical Affairs-Clinical Governance Office.
   • - Collect the diagnostics variables, procedure medication, intra & post procedure events, comorbidity and lab results as well as treatment plan (optimized medical, revascularization procedure).
   • - Prepare and submit audited data to the respective authority accurately and timely.
   • - Perform additional Operations and Administrative tasks as assigned by the supervisor.
3. 3) Perform additional Operations and Administrative tasks as assigned by the supervisor.

Requirements

Qualification Required and Area of Discipline

Degree in Science or Nursing

Required Competencies and Capabilities (Skills, Experiences and Professional Licences)

• - At least 3 years’ working experience in healthcare settings- Good verbal and written communication skills
• - Strong interpersonal skills with the ability to engage and work with all levels of staff
• - Have a positive and proactive mindset
• - A good team player who is able to work independently