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 FunctionsReferral 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 escalate 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- Experience with PACE, managed care, complex care management, or transitions of care.
- Experience working in interdisciplinary teams.
$125,000 - $1,350,000 a year
Benefits That Support YouWe're committed to supporting our team's well-being. Our comprehensive benefits package includes:
Health & Wellness- 100% employer-paid medical, dental & vision coverage
- Acupuncture & chiropractic coverage
Time Off- 12 vacation days
- 12 sick days
- 12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)
Financial & Retirement- 403(b) with 3% employer contribution + up to 2% match
- Flexible Spending Account (FSA) & Dependent Care Assistance
Additional Support- Commuter benefits
- Long-Term Disability Insurance
Please note: We are not seeking support from staffing agencies at this time. Direct applicants only.
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
