Community Health Navigator – Rural Outreach

Asian American Center of Frederick; Frederick (MD); Sur place; USD 45 000 - 50 000; Plein temps

Résumé du poste

Asian American Center of Frederick (AACF) is seeking a Community Health Worker to connect high-risk adults with primary care, support chronic disease self-management, and resolve social barriers to avoidable hospital use. The role involves risk-based home visits, intake, risk stratification, and coordination of services across transportation, housing, and benefits.

The ideal candidate has MDH CHW certification (or ability to obtain during onboarding), is connected to the local community, and can

Qualifications

• MDH CHW certification required or in onboarding process.
• From or closely connected to the communities served.
• 2+ years CHW/home-visiting experience preferred.
• Strong trust-building, motivational, and de-escalation skills.
• Comfortable with smartphones/tablets and data entry.
• Reliable transportation and valid driver’s license.

Responsabilités

• Receive and respond to hospital referrals; supplement with outreach.
• Conduct multilingual intake and risk stratification in internal system.
• Perform risk-based home visits and document medication observations.
• Link participants to a suitable primary care home.
• Support DSMES and SMBP self-management and teach-back.
• Coordinate closed-loop referrals for transportation, housing, benefits.
• Follow up at 30/60/90/180 days; monitor re-engagement triggers.
• Escalate clinically via RN triage and referrals when needed.
• Present cases in partner meetings and maintain non-clinical boundaries.
• Facilitate transition to peer support and maintenance as appropriate.
• Document all interactions in Salesforce; protect HIPAA privacy.

Connaissances

CHW certification

Community ties

In-home visits

Trust-building

De-escalation

Smartphones/tablets

Data entry

Salesforce

Driver's license

Outils

Salesforce

Description du poste

Asian American Center of Frederick (AACF) is seeking a Community Health Worker to connect high-risk adults with primary care, support chronic disease self-management, and resolve social barriers to avoidable hospital use. The role involves risk-based home visits, intake, risk stratification, and coordination of services across transportation, housing, and benefits.

The ideal candidate has MDH CHW certification (or ability to obtain during onboarding), is connected to the local community, and can