In-Clinic Clinical Scribe & Documentation Specialist

CVS Health; United States; On-site; USD 23,000 - 39,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

Oak Street Health is seeking a Clinical Informatics Specialist (Medical Scribe) to support primary care providers with real-time documentation during patient encounters. You will join exam rooms, observe visits, and document histories, plans, and exams while ensuring accurate coding and timely after-visit summaries.

The role emphasizes clinical documentation improvement, population health tools, and collaboration with the care team, with on-site work and full-time hours.

Qualifications

• Knowledge of medical terminology and common medications, either from a pre-medical degree or prior clinical experience [required]
• Prior clinical experience, including shadowing and/or volunteering [strongly preferred]
• Prior scribe or transcription experience [preferred but not required]

Responsibilities

• Documenting Patient Encounters ~ 80%
• 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 Oak Street's population health tools to support clinical documentation improvement
• Preparing for and supporting Daily Huddles and Clinical Documentation Reviews
• Consulting with provider on clinical documentation opportunities
• Administrative support for your provider and care team ~ 10%
• Placing orders and referrals
• Addressing tasks
• Supporting the care team with additional responsibilities related to clinical documentation
• Other duties as assigned

Skills

Advanced listening and communication

Computer literacy

Languages (Spanish/Polish/Russian)

Job description

Oak Street Health is seeking a Clinical Informatics Specialist (Medical Scribe) to support primary care providers with real-time documentation during patient encounters. You will join exam rooms, observe visits, and document histories, plans, and exams while ensuring accurate coding and timely after-visit summaries.

The role emphasizes clinical documentation improvement, population health tools, and collaboration with the care team, with on-site work and full-time hours.