CHW - Community Health Worker in Frederick, Maryland at Life & Discovery Inc

AACF is looking for experienced Community Health Workers to help us expand our services to the more rural areas of Frederick County. Our CHWs work with the Frederick Health Hospital system to connect high-risk adults to a primary care medical home, support chronic disease self-management, and resolve the social barriers that drive avoidable hospital use. This role carries a caseload of high-need, high-acuity participants and delivers risk-based home visits, comprehensive intake and risk stratification, closed-loop referrals, chronic disease self-management support, and structured follow-up — holding participants in care and re-engaging them when they destabilize.

• Receive and respond to hospital referrals from Frederick Health Hospital at ED or inpatient discharge; supplement with community outreach and direct recruitment.

• Complete comprehensive, multilingual intake, SDOH screening, and risk stratification in our internal database.

• Conduct risk-based home visits — weekly for high-risk participants, stepping down as participants stabilize — and document a standardized medication observation, reporting concerns to the RN Care Coordinator.

• Link participants to a primary care medical home that matches their needs.

• Support diabetes self-management (DSMES-aligned) and hypertension self-measured blood pressure (SMBP) monitoring; reinforce provider care plans using teach-back and plain-language materials.

• Coordinate and track closed-loop referrals for transportation, food, insurance and benefits, medication access, housing, and language access.

• Conduct structured follow-up at 30, 60, 90, and 180 days; monitor re-engagement triggers (missed appointments, medication barriers, new ED use, worsening chronic disease) and return participants to active support as needed.

• Activate clinical escalation through RN triage guidance, and support primary-care-directed referral to Chronic Care Management services when appropriate.

• Present cases at partner coordination / case review meetings; maintain clear non-clinical scope-of-practice boundaries.

• Support participants’ transition to peer support and lower-intensity maintenance as they stabilize.

• Document every contact, referral, and outcome in Salesforce; protect participant privacy under HIPAA.

• Maryland Department of Health (MDH) CHW certification. (As an MDH-accredited CHW Training Center, AACF can support certification within the onboarding period for an otherwise strong candidate.)

• From or closely connected to the communities served.

• Two or more years of CHW, home-visiting, or comparable community health experience preferred.

• Strong trust-building, motivational, and de-escalation skills; comfort working in participants’ homes and managing complex, high-acuity cases.

• Comfortable with smartphones, tablets, and data entry (Salesforce experience a plus).

• Reliable transportation and valid driver’s license for community-based work and home visits.

• Experience supporting chronic disease (diabetes, hypertension, cardiovascular) self-management.

• Familiarity with Frederick County’s health and social-service landscape, including the ENOUGH Census Tract communities.

• Bilingual Spanish.

• Community-based role with regular travel across Frederick County, including home visits and partner sites.

• Ability to lift light materials, navigate varied home and community environments, and work occasional evenings or weekends for outreach.

connect high-risk adults to a primary care medical home, support chronic disease self-management, and resolve the social barriers that drive avoidable hospital use.

This job description should not be interpreted as all-inclusive. It is intended to identify the essential functions and requirements of this job.

Asian American Center of Frederick is an equitable and inclusive organization. Embracing diversity is central to our mission, and we encourage and seek applications from people of all backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, age, protected veteran or disabled status, or genetic information.

Founded in 2005, the Asian American Center of Frederick (AACF) is a minority-led 501(c)(3) community-based organization whose mission is to enrich the future of Maryland by equipping and empowering all immigrants to become independent and self-sufficient contributors to their communities and American society. AACF provides culturally responsive health and social services to more than 3,000 individuals annually, maintains a multilingual workforce serving 30+ languages, and is a Maryland Department of Health–accredited Community Health Worker Training Center.