Job Summary: The Intake / Outreach Manager, RN is responsible for overseeing the clinical intake and enrollment coordination function for prospective PACE participants-from referral through enrollment-ensuring timely, accurate, and compliant completion of required screenings, assessments, documentation, and interdisciplinary decision-making. This role leads and supports Intake Coordinator(s) and serves as a senior clinical point of contact for referral sources, prospective participants, and caregivers during intake. The manager partners closely with the Interdisciplinary Team (IDT), eligibility/enrollment staff, and contracted/community providers to support a smooth transition into PACE services and to continuously improve intake workflows and performance.
Essential Job FunctionsPeople management & team leadership- Supervise, coach, and develop Intake Coordinator(s) and related intake support staff (as applicable); set clear expectations, provide feedback, and support professional growth.
- Coordinate intake team staffing, coverage, and workload balancing to ensure timely response to referrals and completion of enrollment milestones.
- Establish and maintain standard work, training, and job aids for intake workflows; onboard new team members as the program scales.
- Partner with PACE leadership to define intake staffing model and hiring needs over time.
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 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- Active California RN license in good standing.
- 2+ years of clinical nursing experience (geriatrics, primary care, home health, SNF, hospital case management, or similar).
- 1+ year of experience leading, training, or supervising staff (formal or informal).
- Strong assessment, triage, and care coordination skills.
- Experience communicating with older adults and caregivers across diverse backgrounds; commitment to person-centered, culturally responsive care.
- Proficiency with documentation systems (EHR/CRM) and strong organizational skills.
- Current BLS certification (or ability to obtain within an established timeframe).
- Valid driver's license and ability to travel for home visits (as required).
Core competencies- Excellent communication (verbal/written) and follow-through
- Ability to manage multiple intakes simultaneously with strong prioritization
- Comfort navigating ambiguity in a startup environment and improving processes
- Strong attention to detail and compliance mindset
- Collaborative, service-oriented approach with IDT partne
Preferred Qualifications- Experience with PACE, managed care, complex care management, or transitions of care.
- Experience working in interdisciplinary teams.
- Bilingual capacity relevant to AHS participant population
- Collaborative, service-oriented approach with IDT partners
$135,000 - $145,600 a year
Note: 1.0 FTE equals 40 hours per week.
