Community Health Worker (Sr. Assoc.)

About the role

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.

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
• Carefully 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

Requirements

• Certification or formal training as a Community Health Worker (CHW) or related role
• Certification or formal training as a Life Coach (preferred)
• 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
• Experience supporting Diabetes Self-Management Education and Support (DSMES) or similar chronic disease self-management programs (preferred)
• 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
• Familiarity with value-based care or population health models such as MDPCP, PCMH, EQIP-PC, or similar frameworks (preferred)
• Understanding of clinical quality metrics, performance measures, and reporting frameworks used in healthcare or public health programs