Intake & Transition Coordinator

Intake & Transition Coordinator
The Intake & Transition Coordinator serves as a primary point of contact for Medi-Cal members entering Star Nursing's CalAIM programs and assists members throughout the referral, intake, health plan authorization, discharge, placement, and community transition process.
Work Location: Remote / Home-Based
Schedule: Monday-Friday, 9:00 AM-5:30 PM PST
Hours: 40 hours per week
Pay Range: $20.00-$22.00 per hour, based on qualifications and experience
Education, Certification & Experience

• Medical Assistant (MA), Certified Nursing Assistant (CNA), healthcare-related education/certification, or comparable healthcare/direct patient-care experience strongly preferred
• 1-2 years of healthcare, patient coordination, intake, discharge planning, placement coordination, case management support, or related experience preferred.
• Experience in a hospital, SNF, RCFE/ALF, home health agency, physician office, Managed Care Plan, or case management environment preferred.
• Experience working with Medi-Cal populations strongly preferred.
• Knowledge of CalAIM, ECM, Community Supports, ALT, and/or the Assisted Living Waiver (ALW) is highly desirable.
• Experience assisting with hospital or SNF discharge and community placement is a strong plus.

REQUIRED SKILLS & COMPETENCIES

• Excellent telephone, written, verbal, and customer-service skills.
• Ability to manage a high-volume referral workload with strong organization, time management, follow-through, and attention to detail.
• Ability to prioritize urgent referrals and pending discharges.
• Strong problem-solving and critical-thinking skills.
• Ability to identify barriers and proactively work toward resolution.
• Ability to recognize potential clinical concerns and appropriately escalate them.
• Ability to work independently in a remote environment with minimal supervision and collaboratively with an interdisciplinary team.
• Professionalism, compassion, patience, persistence, and accountability.

TECHNOLOGY REQUIREMENTS

• Microsoft Outlook, Word, Excel, and Teams.
• Electronic Medical Record (EMR) systems.
• Managed Care Plan portals.
• CRM and referral-tracking systems.
• Secure electronic communication and virtual meeting platforms.

POSITION SUMMARY
Working as part of Star Nursing's CalAIM Access & Transition Team, the Coordinator works closely with Medi-Cal members and families, Managed Care Plans (MCPs), hospitals, skilled nursing facilities (SNFs), discharge planners, social workers, case managers, healthcare providers, and Residential Care Facilities for the Elderly/Assisted Living Facilities (RCFEs/ALFs).
The Coordinator assists members with accessing Enhanced Care Management (ECM) and Community Supports (CS), with a primary focus on Assisted Living Transition (ALT) and helping eligible members successfully transition from hospitals, skilled nursing facilities, or other settings into appropriate community-based living environments.
This position requires strong healthcare knowledge, organization, communication, persistence, customer service, and the ability to manage a high-volume referral workload while maintaining timely and accurate follow-up.
1. Intake & Referral Coordination

• Receive and process new referrals from Managed Care Plans, hospitals, SNFs, healthcare providers, community organizations, members, families, and other referral sources.
• Respond promptly and professionally to incoming telephone calls, emails, referral requests, and inquiries.
• Conduct initial intake and gather required demographic, insurance, medical, functional, social, and discharge information.
• Verify Medi-Cal and Managed Care Plan information and obtain documentation necessary to support the referral.
• Identify members who may potentially benefit from ECM and/or Community Supports.
• Complete Star Nursing's internal referral and intake documentation accurately and timely.
• Obtain required member consents, releases, and authorization documents.
• Request missing records and documentation from referral sources.
• Submit completed referrals to the appropriate Star Nursing department and/or Managed Care Plan.
• Maintain communication with the member, family/authorized representative, and referral source throughout the intake process.
• Track referrals from initial receipt through authorization, placement, transition, or closure.

2. CalAIM - ECM & Community Supports Coordination

• Assist Medi-Cal members with navigating the CalAIM referral and enrollment process.
• Educate members, families, healthcare professionals, and referral partners regarding Star Nursing's ECM and Community Supports programs.
• Assist with referrals for Enhanced Care Management (ECM) and applicable Community Supports (CS) services.
• Maintain a primary focus on members requiring Assisted Living Transition (ALT) and community-based placement.
• Coordinate with Managed Care Plans regarding referral status, eligibility, authorization requests, service approvals, and outstanding documentation.
• Follow up consistently on pending referrals and authorizations to prevent avoidable delays.
• Identify potential barriers to enrollment or service authorization and work with the appropriate parties to resolve them.
• Identify members who may potentially benefit from additional services and refer those needs to the appropriate Star Nursing team.
• Escalate health plan barriers, eligibility concerns, authorization delays, or other significant issues to program leadership.

3. Hospital & Skilled Nursing Facility Discharge Coordination

• Work directly with hospital and SNF discharge planners, social workers, case managers, nurses, and other healthcare professionals.
• Assist with identifying Medi-Cal members who may be appropriate for transition from institutional care into an RCFE/ALF or other community-based setting.
• Determine the anticipated discharge date and maintain regular communication with the discharge planning team.
• Obtain and organize documentation required to facilitate transition and placement, including available medical records, medication lists, physician documentation, functional information, and behavioral information.
• Coordinate with Star Nursing clinical and case management teams regarding member needs and potential placement concerns.
• Assist with coordinating discharge and transition once appropriate authorization and placement have been secured.
• Maintain active follow-up until the member has successfully transitioned or the referral is formally closed.
• Proactively identify and address barriers such as Medi-Cal/MCP issues, pending authorizations, missing documentation, placement difficulty, member/family concerns, clinical or behavioral needs, medications, insulin, oxygen, DME, transportation, and room-and-board concerns.
• Promptly escalate unresolved clinical, discharge, or safety concerns to the appropriate clinical staff or program leadership.

4. RCFE/ALF Placement & Assisted Living Transition

• Identify appropriate RCFEs/ALFs with available beds for members requiring community placement.
• Maintain regular communication with Star Nursing's network of RCFE/ALF providers.
• Contact facilities regarding bed availability and potential member acceptance.
• Assist with matching placement options to documented needs and preferences, including geography, mobility, transfers, ADLs, cognition, dementia/memory care, behavior, medications, insulin, oxygen, DME, toileting, dietary/swallowing needs, therapy needs, room-and-board resources, and member/family preferences.
• Prepare and submit member placement packets to prospective RCFEs/ALFs following appropriate authorization and consent.
• Coordinate facility interviews, assessments, virtual evaluations, and in-person evaluations when required.
• Follow up regarding acceptance, denial, or requests for additional information and document the outcome of each placement inquiry.
• Communicate available placement options to the member and/or authorized representative and support informed member choice.
• Once accepted, coordinate with the facility, discharge planner, health plan, member/family, and Star Nursing team to establish a transition date.
• Ensure required documentation is provided to the accepting facility and assist with transportation and other transition needs with the appropriate parties.
• Confirm successful arrival and placement and complete a timely handoff to the appropriate Star Nursing ECM/Community Supports team.

5. Member & Family Support

• Serve as a consistent point of contact throughout intake, authorization, discharge, placement, and transition.
• Explain the process in clear, understandable language and provide timely status updates.
• Assist members and families with understanding required documentation and information.
• Facilitate communication among members, authorized representatives, discharge planners, health plans, placement facilities, and Star Nursing staff.
• Respect member preferences and the member's right to participate in placement and transition decisions.
• Identify concerns or dissatisfaction early and escalate complaints, safety concerns, or significant issues to appropriate leadership.

6. Outreach & Referral Development

• Conduct outreach to hospitals, SNFs, discharge planners, social workers, case managers, home health agencies, healthcare providers, and community organizations.
• Introduce and explain Star Nursing's CalAIM ECM and Community Supports programs to new referral partners.
• Build and maintain professional relationships with referral sources and conduct consistent follow-up.
• Identify opportunities to increase appropriate referrals for ECM, ALT, and other Star Nursing programs.
• Participate in virtual and in-person outreach activities as assigned and represent Star Nursing professionally.

7. Referral Pipeline & Case Tracking

• Maintain an accurate and current referral tracker and know the current status, outstanding barriers, and next required action for every assigned referral.
• Document significant outreach attempts, communications, and case updates.
• Follow up on outstanding items within established timelines and prioritize pending hospital and SNF discharges.
• Proactively identify stalled referrals and follow up with responsible parties.
• Escalate barriers that cannot be resolved at the Coordinator level.
• Provide referral, authorization, discharge, and placement status reports to leadership as requested.

REFERRAL WORKFLOW
Referral Received → Intake Completed → Medi-Cal/MCP Verified → Consent Obtained → ECM/CS Referral Submitted → Health Plan Review → Authorization/Approval → Placement Search → Facility Review → Facility Acceptance → Discharge/Transition Scheduled → Member Placed → Handoff to Ongoing Case Management
8. Healthcare Knowledge & Scope
Because this position works with medically, functionally, and socially complex Medi-Cal members, Star Nursing strongly prefers candidates with previous healthcare or direct patient-care experience.

• Working knowledge of medical terminology, ADLs, mobility and transfers, fall risk, cognitive impairment/dementia, behavioral and mental health concerns, medication management, diabetes/insulin, oxygen/respiratory needs, DME, incontinence/toileting, wound care, dietary/swallowing needs, home health/therapy services, and functional limitations.
• Recognize, gather, document, and communicate relevant healthcare information to the appropriate team.
• Do not independently diagnose, establish a plan of care, or make clinical determinations outside the employee's professional license or assigned scope of responsibility.
• Escalate clinical questions, changes in condition, or concerns regarding placement appropriateness or safety to the appropriate RN or licensed clinical professional.

9. HIPAA, Compliance & Confidentiality

• Maintain confidentiality of Protected Health Information (PHI) in accordance with HIPAA, company policy, and applicable contractual requirements.
• Follow Star Nursing policies and procedures related to ECM, Community Supports, ALT, member consent, documentation, referrals, placement, and care transitions.
• Maintain complete, accurate, objective, and timely documentation.
• Remain within assigned responsibilities and professional scope of practice.
• Immediately escalate significant clinical changes, member safety concerns, suspected abuse or neglect, complaints, or other significant concerns according to company policy.
• Participate in required staff training, quality improvement activities, audits, and corrective action activities.
• Maintain professional conduct in all communications.

PERFORMANCE EXPECTATIONS

• Timeliness of initial referral outreach and accuracy/completeness of intake documentation.
• Number of referrals successfully processed and progressed through the transition pipeline.
• Timeliness of ECM/Community Supports submissions and follow-up on pending MCP authorizations.
• Successful ALT/community placements and referral-to-transition turnaround times.
• Timely identification and resolution of discharge barriers.
• Responsiveness to members, families, hospitals, SNFs, health plans, and placement facilities.
• Accuracy and completeness of referral tracking.
• Development and maintenance of referral relationships.
• Quality of communication, customer service, successful member transitions, handoffs, and compliance.

Quality, member choice, and appropriate placement take priority over placement volume. Members should not be directed toward a setting that does not appropriately meet their documented needs.