Medical Scribe

CVS Health•Fort Wayne, IN

5d•$17 - $26•Onsite

About The Position

The Medical Scribe, internally referred to as a Clinical Informatics Specialist (CIS), supports Oak Street Health primary care providers by handling clinical documentation so providers can focus on patient care. Scribes plan for the day’s visits with providers, observe and document encounters in the exam room, and help with follow-up steps after visits. They document patient encounters in real time, prepare after-visit summaries, assign CPT and ICD-10 codes, and consult with providers to ensure documentation is accurate and specific. The role also supports clinical documentation improvement by requesting and reviewing medical records, using population health tools, preparing for daily huddles and clinical documentation reviews, and identifying documentation opportunities with providers. Scribes also assist their provider and care team with orders, referrals, tasks, and other documentation-related responsibilities. The position offers on-the-job training in clinical workflows, value-based medicine, preventative care for chronic conditions, documentation, population health data, and team-based care. A commitment of at least one year is required, with two or more years considered ideal. This is a full-time, in-person clinic role, typically requiring approximately 40–45 hours per week during clinic hours.

Requirements

Knowledge of medical terminology and common medications, obtained 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 a member 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 attendance and ability to work in person in 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 a structured note, including the history of the 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’s 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.