Clinical Documentation Specialist — Medical Scribe

CVS Pharmacy; Gastonia (NC); On-site; USD 23,000 - 39,000; Full time

Benefits offered by this job

Comprehensive benefits package

Job summary

Oak Street Health in Gastonia, NC is seeking a Medical Scribe to support our primary care providers with real-time clinical documentation and accurate coding. You will join in the exam room to observe visits, document encounters, and ensure organized notes for efficient patient care.

The role emphasizes CPT/ICD-10 coding, population health documentation, and collaboration across the care team. This full-time position offers comprehensive benefits and in-clinic hours.

Qualifications

• Knowledge of medical terminology and common medications [required]
• Advanced listening and communication skills [required]
• Strong computer literacy and ability to learn new technical workflows [required]
• Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve [required where indicated]

Responsibilities

• Joining the provider in the exam room to observe patient visits
• Documenting patient encounters in a structured note, including the history of the present illness, assessment, plan, and physical exam
• Assigning appropriate CPT and ICD-10 codes
• Preparing After Visit Summaries
• Consulting with provider to ensure accurate and specific documentation
• Clinical Documentation Improvement ~ 10%: Requesting and reviewing medical records; leveraging population health tools; preparing for daily huddles and reviews; other documentation opportunities
• Administrative support for the provider and care team ~ 10%: placing orders and referrals; addressing tasks; supporting the care team with documentation

Skills

Medical terminology

Advanced listening

Strong computer literacy

Spanish proficiency

Polish proficiency

Russian proficiency

Job description

Oak Street Health in Gastonia, NC is seeking a Medical Scribe to support our primary care providers with real-time clinical documentation and accurate coding. You will join in the exam room to observe visits, document encounters, and ensure organized notes for efficient patient care.

The role emphasizes CPT/ICD-10 coding, population health documentation, and collaboration across the care team. This full-time position offers comprehensive benefits and in-clinic hours.