Intake Coordinator - Registered Nurse

California School-Based Health Alliance

San Leandro, Northern (CA, KY)

Hybrid

USD 125,000 - 1,350,000

Full time

9 days ago

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Benefits offered by this job

Health & Wellness

Time Off

Financial & Retirement

Commuter benefits

Long-Term Disability Insurance

Job summary

Asian Health Services is seeking a PACE Intake Coordinator to educate potential participants and caregivers about the PACE program and assess eligibility. The role includes setting intake appointments, gathering medical and social information, and coordinating pre-enrollment assessments.

You will conduct home visits as needed and maintain accurate intake documentation in our EHR/CRM while ensuring CMS compliance. Strong nursing background and bilingual capabilities are preferred.

Qualifications

Graduate of an accredited nursing program with active RN license.
Experience in geriatrics, primary care, home health, SNF, or hospital case management.
Strong assessment, triage, and care coordination skills.

Responsibilities

Educate potential participants and caregivers on PACE benefits.
Schedule intake appointments and document medical needs.
Gather medical and social information during enrollment process.
Coordinate pre-enrollment assessments and home visits as needed.
Maintain intake documentation in EHR/CRM per policy and CMS requirements.
Support readiness for audits and site visits.

Skills

RN licensure

Geriatrics care

Care coordination

BLS certification

Communication with diverse groups

Education

Registered nursing degree

Tools

EHR/CRM

Job description

Imagine a center where our seniors can receive transformative health care that will allow them to age at home and in their communities.

At Asian Health Services, we recognize that so many of our elderly patients continue to struggle to get the care they need because of challenges that go beyond the walls of the clinic.

To address these gaps, we’ve found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve.

We are building aProgram of All-Inclusive Care for the Elderly (PACE) to bring life-changing, culturally competent care to low-income seniors—supporting them as they age safely and with dignity, right in their communities. Based on the PACE model, SpringLight Health will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support—all tailored to each individual’s needs.

Learn more by visiting our website here.

Job Summary:

The PACE Intake Coordinator is responsible for educating potential participants and their caregivers on the benefits of the PACE program and evaluates potential participants to determine eligibility. The PACE Intake Coordinator will work independently to set intake appointments and document incoming participants’ medical needs. They will gather crucial medical and social information for new participants during the enrollment process by phone, at the participant’s home and/or the PACE Day Center.

Essential Job Functions

Referral management & pre-enrollment clinical coordination

Receive, triage, and track referrals in collaboration with intake/enrollment staff; ensure referral completeness and prioritize based on acuity and program capacity.
Conduct or coordinate initial clinical screening (phone/in-person) to confirm appropriateness for PACE and identify immediate risks or care needs.
Obtain and review relevant clinical records (hospital/SNF notes, medication lists, problem lists, recent labs/imaging as applicable) to support eligibility determination and IDT review.
Coordinate scheduling and completion of required pre-enrollment assessments (e.g., nursing assessment, social work, PT/OT, nutrition, behavioral health as applicable) and ensure timely follow-up on outstanding items.
Conduct home visits as needed to assess initial level of care needs, functional status, and home safety/barriers.
Complete level of care (LOC) assessments.

Eligibility support & enrollment readiness

Partner with eligibility/enrollment staff to support Medi-Cal/Medicare eligibility workflows and provide clinical clarification when needed.
Prepare clinical summaries for IDT intake review and enrollment decisions, including risk flags, functional status, and care needs.
Ensure required consents, releases of information (ROI), and participant/caregiver education are completed and documented.
Support participant and caregiver understanding of the PACE model of care and what enrollment entails (services, center-based care, 24/7 coverage, PCP assignment, pharmacy, transportation, etc.).

Documentation, compliance, and audit readiness

Maintain accurate, timely, and complete intake documentation in the EHR/CRM per internal policy and CMS/DHCS requirements.
Track intake timelines and required elements to ensure compliance with program standards, including IDT involvement and documentation of enrollment decisions.
Support readiness for audits/site visits by maintaining well-organized intake files and evidence of required processes.
Maintain current knowledge of and adhere to Medicare/PACE prohibited marketing practices and applicable outreach/marketing guidance.

Operations, performance, and continuous improvement

Own intake pipeline visibility and performance reporting (e.g., referral volume, cycle time to screening, cycle time to IDT decision, conversion rate); identify trends and lead improvement actions.
Facilitate regular intake huddles with the intake team and cross-functional partners (eligibility/enrollment, social work, therapies, clinic) to resolve bottlenecks and ensure smooth handoffs.
Identify and elevate operational risks (capacity constraints, high-risk referrals, documentation gaps) to clinical/operations leadership.

Care transition into PACE

Coordinate handoff from intake to ongoing care teams upon enrollment, including communication of clinical risks, pending needs, and initial care plan priorities.
Ensure initial appointment scheduling (PCP visit, nursing follow-up, therapies) is aligned with participant needs and center capacity.
Coordinate initial medication reconciliation and pharmacy setup in partnership with clinic nursing/pharmacy partners.

Relationship management & community outreach support

Build and maintain relationships with key referral sources (health systems, SNFs, community providers, social services, CBOs) to facilitate high-quality referrals and clear expectations.
Provide clinical education to referral partners about PACE appropriateness criteria and the intake/enrollment workflow.
Closely track referral data and partner with PACE leadership to identify trends, bottlenecks, and improvement opportunities.

Minimum Qualifications

Graduate of an accredited School of Nursing.
Active California RN license in good standing.
Ability to speak English and Cantonese and/or Mandarin.
Experience communicating with older adults and caregivers across diverse backgrounds; commitment to person-centered, culturally responsive care.
Strong assessment, triage, and care coordination skills.
Proficiency with documentation systems (EHR/CRM) and strong organizational skills.
2+ years of clinical nursing experience (geriatrics, primary care, home health, SNF, hospital case management, or similar).
Current BLS certification (or ability to obtain within an established timeframe).
Valid driver’s license and ability to travel for home visits (as required).

Preferred Qualifications