Intake Coordinator - Registered Nurse

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 a
Program 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,
Spring Light 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.

• 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.

• 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.).

• 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.

• 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…