Life & Discovery Inc·Frederick County, Maryland
Provide intensive, relationship-based care coordination and risk-based home visits for high-risk adults. Manage a caseload involving intake, SDOH screening, chronic disease self-management support, and closed-loop referrals.
As a Community Health Worker, Level 2, you will provide intensive, relationship-based care coordination for high-risk adults identified through Emergency Department and inpatient discharge referral pathways and through community outreach. You will carry a caseload of high-acuity patients, and deliver 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.
Key responsibilities
Receive and respond to hospital referrals from the ED or inpatient discharge; supplement with community outreach and direct recruitment.
Complete comprehensive, multilingual intake, SDOH screening, and risk stratification in Salesforce.
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.
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 clinical partners for Chronic Care Management 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.
Required qualifications
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.)
Bilingual; 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; comfortable working in participants’ homes and managing complex, high-acuity cases.
Comfortable with smartphones, tablets, and data entry (Salesforce experience a plus).
Reliable transportation and a valid driver’s license for community-based work and home visits.
*Studies have shown that women and people of color are less likely to apply for jobs unless they believe they can perform every job description task. We are most interested in finding the best candidate for the job, and that candidate may come from a less traditional background. AACF may consider an equivalent combination of knowledge, skills, education, and experience to meet minimum qualifications. If you are interested in applying, we encourage you to think broadly about your background and skill set for the role.
• $48,000 to $52,000 annually, depending on experience
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.
Requires Maryland Department of Health CHW certification and bilingual proficiency. Preferred candidates have two or more years of community health experience and a valid driver's license.
Market context
In Maryland, Community Health Worker Level 2 roles typically draw candidates with state CHW certification, bilingual ability, and community-based experience, especially where outreach and care coordination are central. These jobs can be competitive because employers often look for applicants who can work independently, communicate across languages, and meet transportation needs; the requirements and benefits here are AI-summarized from the original job description to save you research time. Before applying, confirm your Maryland Department of Health certification status and note any experience with local community programs.
