Intake Coordinator CantoneseMandarin (RN License)

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 weve 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.

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.
• Partners closely with theOutreachteamEnrollmentRN IDTandcenter leaders to deliver a coordinated participant-centeredenrollmentexperience.

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.