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
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.
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.
