Medical Scribe

CVS Health•Freeport, NY

2d•Onsite

About The Position

The Medical Scribe, internally known at Oak Street Health as a Clinical Informatics Specialist (CIS), supports primary care providers by documenting clinical encounters and helping providers focus on patient care. The Scribe participates in daily huddles, observes and documents patient visits in real time, and follows up with the provider on next steps. The role includes supporting accurate, specific, and timely clinical documentation, using ICD-10 and CPT coding knowledge, and helping providers identify and address care gaps. Extensive on-the-job training is provided in clinical workflows, value-based medicine, preventive care for chronic conditions, documentation, population health data, and team-based care. The position is full-time, in person at the clinic, Monday through Friday from 8:00 a.m. to 5:00 p.m., with approximately 40–45 hours per week. Candidates are expected to commit to at least one year in the role; two or more years is ideal.

Requirements

Knowledge of medical terminology and common medications, gained through a pre-medical degree or prior clinical experience.
Advanced listening and communication skills.
Strong computer literacy and ability to learn new technical workflows.
Ability to adapt to new workflows and quickly learn new concepts and skills.
Ability and willingness to take direction and work as part of a patient-care team, including adapting to the provider's working style.
Ability to be a self-starter within the scope of the role.
Excellent job attendance and ability to work in person in the clinics.
Ability to commit to at least one year in the role.
Ability to work approximately 40–45 hours per week during clinic hours.
Compliance with hospital and Oak Street Health policies, including HIPAA.
US work authorization.

Nice To Haves

Prior clinical experience, including shadowing and/or volunteering.
Prior scribe or transcription experience.
Ability to type 70 or more words per minute.
Fluency in Spanish, Polish, Russian, or other languages spoken in the communities served, where indicated.
Commitment to two or more years in the role is ideal.

Responsibilities

Join the provider in the exam room to observe patient visits.
Document patient encounters in structured notes, including the history of present illness, assessment, plan, and physical exam.
Assign appropriate CPT and ICD-10 codes.
Prepare After Visit Summaries.
Consult with providers to ensure accurate and specific documentation.
Request and review medical records.
Use Oak Street Health population health tools to support clinical documentation improvement.
Prepare for and support daily huddles and Clinical Documentation Reviews.
Consult with providers about clinical documentation opportunities.
Place orders and referrals.
Address tasks and support the care team with additional clinical documentation responsibilities.
Perform other duties as assigned.