Community Health Worker (Sr. Assoc.)

Medicalincs, LLC•Silver Spring, MD

17d

About The Position

We are seeking a Community Health Worker (CHW)/Diabetes Prevention Coach with case management experience to support individuals at risk for diabetes through education, care coordination, and ongoing engagement. This role is essential to advancing our diabetes prevention and chronic disease management initiatives and plays a key part in improving patient outcomes while supporting program growth and sustainability. The ideal candidate is community‑focused, highly organized, comfortable with documentation and follow‑up, and experienced in working with diverse populations. Responsibilities Deliver evidence‑based Diabetes Prevention Program (DPP) and Diabetes Self‑Management Education & Support (DSMES) services in alignment with CDC guidelines and clinical standards Support individuals and families across the continuum from prediabetes to chronic disease self‑management Facilitate engaging one-on-one and group education sessions (in‑person, virtual, or hybrid) focused on lifestyle change, nutrition, physical activity, and behavior support Coordinate care within MDPCP/EQIP‑PC or similar care delivery models, including follow‑ups, referrals, and closing care gaps Provide participant-centered case management, including care coordination, referrals, follow‑up outreach, and ongoing support Identify and address social determinants of health and connect participants to appropriate community-based resources Support participant enrollment, retention, and sustained engagement in diabetes prevention and self-management programs Build trusting relationships that promote participation, goal setting, and long-term behavior change Track participant goals, progress, and outcomes using electronic health records or program databases Maintain accurate, timely documentation in compliance with program, accreditation, and reporting requirements Contribute to continuous quality improvement and program reporting efforts Perform other related duties as assigned OTHER DUTIES Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with a reasonable notice. Moderate degree of mental/visual stress involved. Concentrated periods of time spent using PC keyboard and viewing monitor. Will work some weekends, evenings or early hours to accommodate member needs.

Requirements

Certification or formal training as a Community Health Worker (CHW) or related role
Case management experience in healthcare, public health, or community‑based settings
Experience working with individuals with or at risk for diabetes, prediabetes, or other chronic conditions
Experience supporting community-based prevention, care coordination, or self-management efforts
Strong communication and interpersonal skills, including motivational interviewing and participant engagement
Ability to build rapport, engage diverse populations, and support behavior change
Comfortable with documentation, data tracking, and use of electronic health records or program databases
Ability to work independently while also contributing effectively as part of a multidisciplinary care team
Understanding of clinical quality metrics, performance measures, and reporting frameworks used in healthcare or public health programs

Nice To Haves

Certification or formal training as a Life Coach (preferred)
Experience supporting Diabetes Self‑Management Education and Support (DSMES) or similar chronic disease self-management programs (preferred)
Familiarity with value‑based care or population health models such as MDPCP, PCMH, EQIP‑PC, or similar frameworks (preferred)

Responsibilities

Deliver evidence‑based Diabetes Prevention Program (DPP) and Diabetes Self‑Management Education & Support (DSMES) services in alignment with CDC guidelines and clinical standards
Support individuals and families across the continuum from prediabetes to chronic disease self‑management
Facilitate engaging one-on-one and group education sessions (in‑person, virtual, or hybrid) focused on lifestyle change, nutrition, physical activity, and behavior support
Coordinate care within MDPCP/EQIP‑PC or similar care delivery models, including follow‑ups, referrals, and closing care gaps
Provide participant-centered case management, including care coordination, referrals, follow‑up outreach, and ongoing support
Identify and address social determinants of health and connect participants to appropriate community-based resources
Support participant enrollment, retention, and sustained engagement in diabetes prevention and self-management programs
Build trusting relationships that promote participation, goal setting, and long-term behavior change
Track participant goals, progress, and outcomes using electronic health records or program databases
Maintain accurate, timely documentation in compliance with program, accreditation, and reporting requirements
Contribute to continuous quality improvement and program reporting efforts
Perform other related duties as assigned