PACE Intake and Outreach Manager (RN)
Job Summary
The PACE Intake and Outreach Manager is responsible for coordinating and supporting the intake and enrollment process for prospective participants in the Program of All-Inclusive Care for the Elderly (PACE). The position serves as the primary point of contact for prospective participants, caregivers, referral sources, and community partners throughout the intake process and helps ensure that prospective participants receive timely, accurate, and comprehensive information about PACE eligibility, services, and enrollment.
The PACE Intake and Outreach Manager conducts initial clinical and eligibility screenings, gathers and evaluates medical, functional, psychosocial, and other information needed to support enrollment and level-of-care determinations, and coordinates enrollment activities with the PACE Interdisciplinary Team (IDT), the State Administering Agency (SAA), and other appropriate parties. The position also educates prospective participants and caregivers about the PACE model of care and assists them in navigating the enrollment process.
As a secondary responsibility, the PACE Intake and Outreach Manager supports PACE community outreach and the development of referrals. This includes maintaining relationships with hospitals, physician practices, skilled nursing facilities, home health agencies, senior housing providers, community-based organizations, and other potential referral sources; providing general education about PACE; participating in community events and outreach activities; and helping increase community awareness of the PACE program. All outreach and referral activities comply with applicable PACE marketing requirements and prohibitions on marketing practices.
Position Responsibilities
· Coordinates all aspects of the prospective participant intake and enrollment process, ensuring timely progression of referrals from initial inquiry through enrollment or other disposition.
· Serves as the primary point of contact for prospective participants, caregivers, referral sources, and other individuals involved in the intake and enrollment process.
· Conducts initial PACE eligibility screenings and enrollment assistance to determine whether prospective participants appear to meet applicable PACE eligibility requirements.
· Educates prospective participants and their caregivers on the PACE model of care, available services, participant rights and responsibilities, enrollment requirements, and the general enrollment process.
· Collects and reviews medical records, demographic information, social history, financial and eligibility information, consents, authorizations, and other documentation required to support enrollment.
· Conducts nursing assessments and collects information on prospective participants' physical, medical, functional, cognitive, social, behavioral, and emotional needs to support enrollment and care planning.
· Conducts home visits, as appropriate, to assess prospective participants' functional status, home environment, support systems, and other factors relevant to eligibility and level-of-care determinations.
· Identifies potential clinical, functional, social, environmental, or caregiver-related concerns and communicates relevant findings to the appropriate PACE IDT members.
· Coordinates level-of-care determination activities with the SAA and other appropriate entities, ensuring that required clinical information and supporting documentation are submitted in a timely manner.
· Determines or verifies eligibility for Medicare and Medicaid, as appropriate, and coordinates with internal and external resources to resolve eligibility issues.
· Assists prospective participants and caregivers with the Medicaid application process, when applicable, and helps facilitate the collection of required documentation.
· Coordinates prospective participant visits, assessments, appointments, and tours of the PACE center as part of the enrollment process.
· Presents prospective participant information to the PACE IDT before enrollment and communicates identified medical, functional, psychosocial, environmental, and service needs to support a safe and effective transition into the program.
· Maintains accurate, complete, and timely documentation of referral, intake, assessment, eligibility, and enrollment activities in accordance with organizational policies and applicable regulatory requirements.
· Maintains ongoing communication with prospective participants and caregivers throughout the enrollment process, providing updates on outstanding requirements, next steps, and anticipated timelines.
· Delivers professional, responsive, and respectful customer service to prospective participants, caregivers, referral sources, community partners, and other stakeholders.
Referral Source and Community Outreach
· Supports the development and maintenance of productive relationships with community referral sources, including hospitals, physician practices, skilled nursing facilities, assisted living communities, home health agencies, social service organizations, senior housing providers, and other organizations serving older adults.
· Conducts outreach to existing and prospective referral sources to provide general education on PACE eligibility, services, the referral process, and the populations that may benefit from the PACE model of care.
· Serves as an accessible resource for referral partners by answering questions, facilitating referrals, and helping community providers understand when and how to refer individuals for PACE consideration.
· Participates in community outreach activities, including educational presentations, health fairs, senior events, provider meetings, and other community engagement opportunities to raise awareness and understanding of the PACE program.
· Develops and maintains relationships with community organizations and stakeholders that serve or engage PACE-eligible older adults.
· Conducts appropriate follow-up with referral sources regarding referrals and maintains communication that supports strong, long-term referral relationships while safeguarding participant confidentiality.
· Collaborates with PACE leadership and other designated staff to identify opportunities to strengthen referral relationships and increase awareness of PACE throughout the service area.
Referral Tracking, Compliance, and Program Support
· Accurately tracks referrals throughout the intake and enrollment process, including referral source, status, disposition, enrollment outcome, and other information required by the organization.
· Reviews referral and enrollment activity to identify trends, barriers, referral patterns, and opportunities for improvement, and communicates findings to PACE leadership.
· Assists leadership in evaluating referral-source effectiveness and identifying opportunities for targeted community education and outreach.
· Maintains current knowledge of federal and state PACE enrollment requirements, Medicare and Medicaid eligibility requirements applicable to the position, and organizational policies governing intake and enrollment.
· Maintains current knowledge of and consistently adheres to Medicare/PACE marketing requirements and prohibited marketing practices. Ensures that outreach activities are educational, accurate, professional, and compliant with applicable requirements.
· Protects the confidentiality of prospective and current participants’ information and complies with HIPAA, organizational privacy requirements, and other applicable confidentiality standards.
· Collaborates effectively with the IDT, enrollment and eligibility staff, leadership, and other departments to promote an efficient, participant-centered enrollment process.
· Contributes to process improvement and quality initiatives across intake, enrollment, referral management, customer experience, and community outreach.
· Performs other duties consistent with the position and the operational needs of the PACE organization.
Experience & Education
Required
· Graduate of an accredited school of professional nursing.
· Current, unrestricted Registered Nurse (RN) license in the state where services are provided, or eligibility for applicable multistate licensure.
· At least two (2) years of professional nursing experience, preferably with older adults, individuals with complex medical and functional needs, or community-based care.
· (CMS required) One year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from PACE on working with a frail or elderly population before providing direct patient care to PACE participants independently.
· (CMS required) Meet a standardized set of competencies for the specific position description established by PACE before working independently.
· (CMS required) Before engaging in participant care, be medically cleared for communicable diseases and have up-to-date immunizations and vaccines.
· (CMS required) Have not been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act.
· (CMS required) Have not been excluded from participating in Medicare and Medicaid programs.
· (CMS required) Have not been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse.
· Experience conducting nursing assessments, obtaining and reviewing medical histories, and evaluating clinical and functional needs.
· Demonstrated ability to communicate effectively with older adults, caregivers, healthcare professionals, referral sources, and community partners.
· Ability to work independently, organize and prioritize multiple referrals and enrollment activities, and maintain accurate, timely documentation.
· Working knowledge of electronic health records and standard computer software.
· Valid driver's license and ability to travel within the PACE service area to conduct home visits, meet with referral sources, and participate in community outreach activities as required.
Preferred
· Bachelor of Science in Nursing (BSN) from an accredited college or university.
· Three (3) or more years of professional nursing experience, including experience in PACE, geriatrics, home health, community health, care management, long-term care, skilled nursing, or another setting serving medically complex older adults.
· Previous experience with PACE intake, enrollment, eligibility, or participant assessment processes.
· Experience conducting in-home nursing or level-of-care assessments for older adults or individuals requiring long-term services and supports.
· Knowledge of Medicare, Medicaid, and long-term care eligibility processes, including experience assisting individuals or families with Medicaid eligibility or application requirements.
· Experience collaborating with an interdisciplinary healthcare team.
· Experience developing or maintaining professional relationships with healthcare referral sources, including hospitals, physician practices, skilled nursing facilities, assisted living communities, home health agencies, and community-based organizations.
· Experience in providing community education, conducting outreach, delivering presentations, or representing a healthcare organization at community or professional events.
· Familiarity with PACE regulations, enrollment and marketing requirements, and prohibited marketing practices.
· Experience with referral management, customer relationship management (CRM), or similar systems to track referrals, outreach activities, and enrollment outcomes.
· Bilingual or multilingual skills appropriate to the population served by the PACE organization.
· BLS certified.
(prepared by PPAG - modified 8/19/2026)
Pay: $80,000.00 - $90,000.00 per year
Benefits:
- 403(b)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Work Location: In person
