Intake Coordinator (Cantonese/Mandarin)

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, SpringLight 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.Essential Job FunctionsReferral management & pre-enrollment clinical coordinationReceive, triage, and track referrals in collaboration with intake/enrollment staff; ensure referral completeness and prioritize based on acuity and program capacityConduct or coordinate initial clinical screening (phone/in-person) to confirm appropriateness for PACE and identify immediate risks or care needsObtain and review relevant clinical records (hospital/SNF notes, medication lists, problem lists, recent labs/imaging as applicable) to support eligibility determination and IDT reviewCoordinate 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 itemsConduct home visits as needed to assess initial level of care needs, functional status, and home safety/barriersComplete level of care (LOC) assessmentsEligibility support & enrollment readinessPartner with eligibility/enrollment staff to support Medi-Cal/Medicare eligibility workflows and provide clinical clarification when neededPrepare clinical summaries for IDT intake review and enrollment decisions, including risk flags, functional status, and care needsEnsure required consents, releases of information (ROI), and participant/caregiver education are completed and documentedSupport 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 readinessMaintain accurate, timely, and complete intake documentation in the EHR/CRM per internal policy and CMS/DHCS requirementsTrack intake timelines and required elements to ensure compliance with program standards, including IDT involvement and documentation of enrollment decisionsSupport readiness for audits/site visits by maintaining well-organized intake files and evidence of required processesMaintain current knowledge of and adhere to Medicare/PACE prohibited marketing practices and applicable outreach/marketing guidanceOperations, performance, and continuous improvementOwn 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 actionsFacilitate regular intake huddles with the intake team and cross-functional partners (eligibility/enrollment, social work, therapies, clinic) to resolve bottlenecks and ensure smooth handoffsIdentify and escalate operational risks (capacity constraints, high-risk referrals, documentation gaps) to clinical/operations leadershipCare transition into PACECoordinate handoff from intake to ongoing care teams upon enrollment, including communication of clinical risks, pending needs, and initial care plan prioritiesEnsure initial appointment scheduling (PCP visit, nursing follow-up, therapies) is aligned with participant needs and center capacityCoordinate initial medication reconciliation and pharmacy setup in partnership with clinic nursing/pharmacy partnersRelationship management & community outreach supportBuild and maintain relationships with key referral sources (health systems, SNFs, community providers, social services, CBOs) to facilitate high-quality referrals and clear expectationsProvide clinical education to referral partners about PACE appropriateness criteria and the intake/enrollment workflowClosely track referral data and partner with PACE leadership to identify trends, bottlenecks, and improvement opportunitiesMinimum QualificationsExperience communicating with older adults and caregivers across diverse backgrounds; commitment to person-centered, culturally responsive careStrong assessment, triage, and care coordination skillsProficiency with documentation systems (EHR/CRM) and strong organizational skillsGraduate of an accredited School of NursingActive California RN license in good standing2+ 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)Ability to speak Cantonese and/or MandarinPreferred QualificationsExperience with PACE, managed care, complex care management, or transitions of careExperience working in interdisciplinary teamsCertifications, Licenses, RegistrationsActive California RN license in good standingCurrent BLS certification (or ability to obtain within an established timeframe)Benefits That Support YouWe're committed to supporting our team's well-being. Our comprehensive benefits package includes:Health & Wellness100% employer-paid medical, dental & vision coverageAcupuncture & chiropractic coverageTime Off12 vacation days12 sick days12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)Financial & Retirement403(b) with 3% employer contribution + up to 2% matchFlexible Spending Account (FSA) & Dependent Care AssistanceAdditional SupportCommuter benefitsLong-Term Disability InsurancePlease 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. 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