Intake & Outreach Manager (Registered Nurse)

Asian Health Services•San Leandro, CA

1d•Hybrid

About The Position

Asian Health Services is establishing a Program of All-Inclusive Care for the Elderly (PACE) called SpringLight Health, aiming to provide transformative, culturally competent healthcare and support systems for low-income seniors to help them age safely and with dignity in their communities. This program will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support, all tailored to individual needs. The Intake / Outreach Manager, RN will lead the clinical intake and enrollment process for prospective PACE participants, ensuring all screenings, assessments, documentation, and interdisciplinary decisions are completed accurately and compliantly. This role involves supervising Intake Coordinators, acting as a key clinical contact for referrals, and collaborating with the Interdisciplinary Team (IDT) and other providers to ensure a smooth transition into PACE services and to drive continuous improvement in intake workflows.

Requirements

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).

Nice To Haves

Experience with PACE, managed care, complex care management, or transitions of care.
Experience working in interdisciplinary teams.
Bilingual capacity relevant to AHS participant population.

Responsibilities

Supervise, coach, and develop Intake Coordinator(s) and related intake support staff, setting clear expectations and supporting 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, and onboard new team members.
Partner with PACE leadership to define intake staffing model and hiring needs.
Receive, triage, and track referrals, ensuring completeness and prioritizing 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 to support eligibility determination and IDT review.
Coordinate scheduling and completion of required pre-enrollment assessments 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.
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 enrollment details.
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.
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, identifying trends and leading improvement actions.
Facilitate regular intake huddles with the intake team and cross-functional partners to resolve bottlenecks and ensure smooth handoffs.
Identify and escalate operational risks to clinical/operations leadership.
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 is aligned with participant needs and center capacity.
Coordinate initial medication reconciliation and pharmacy setup.
Build and maintain relationships with key referral sources 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.