Care Coordinator, Cardiac Department

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 clinical
outcomes. 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 Role
Patient 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