Intake & Outreach Manager (Registered Nurse)

People 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.