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, and supports 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) 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) 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

About the NATIONAL UNIVERSITY HOSPITAL

The National University Hospital is a tertiary hospital and major referral centre with over 50 medical, surgical and dental specialties, offering a comprehensive suite of specialist care for adults, women and children. It is the only public hospital in Singapore to offer a paediatric kidney and liver transplant programme, in addition to kidney, liver and pancreas transplantation for adults.

The Hospital was opened on 24 June 1985 as Singapore’s first restructured hospital. Each year, the Hospital attends to more than one million patients.

As an academic health institution, patient safety and good clinical outcomes are the focus of the Hospital. It plays a key role in the training of doctors, nurses, allied health and other healthcare professionals. Translational research is pivotal in the Hospital’s three-pronged focus, and paves the way for new cures and treatment.

A member of the National University Health System, it is the principal teaching hospital of the NUS Yong Loo Lin School of Medicine and the NUS Faculty of Dentistry.

For more information, visit

www.nuh.com.sg