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Medical Scribe

Oak Street Health
Raleigh, North Carolina
Full-time

Role Description

The purpose of a Medical Scribe at Oak Street Health is to support our primary care providers with clinical documentation so that they can focus on providing exceptional care to our patients.

Scribes assist providers throughout the patient care journey - huddling each morning to plan for the day's visits, joining them in the exam room to observe and document, and touching base after the visit to assist with next steps.

Beyond the typical Scribe role, these important care team members serve as clinical documentation assistants to their paired provider.

Internally, we call them CISs (Clinic Informatics Specialists) in recognition of their important role in supporting accurate, specific, and timely clinical documentation.

In addition to observing and documenting all patient encounters in real time, our Scribes become experts in our value-based care model and the documentation and care of chronic conditions, including ICD-10 and CPT coding.

Scribes use this expertise to help providers identify and help close care gaps. Scribes receive extensive on-the-job training in clinical workflows, value-based medicine, preventative care for chronic conditions, accurate and specific documentation, population health data streams, and team based care.

Because our patients and providers rely on our Scribes, the ideal candidate should commit at least 1-2 years to this role.

This is an excellent opportunity for pre-med track individuals looking to gain practical, paid experience in a clinical setting before applying to an MD / DO / PA / NP program, as well as those pursuing careers in Health Informatics, Public Health, Healthcare Administration, Medical Coding, and other related fields.

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 orders and referrals

Addressing tasks

Supporting the care team with additional responsibilities related to clinical documentation

Other duties as assigned

What we're looking for

Knowledge

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

Skills

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

Abilities

Ability to adapt to new workflows and to quickly learn new concepts and skills required

Ability to type 70+ words per minute strongly preferred

Ability and willingness to take direction and be a member of a team providing patient care, including adapting to the provider's working style required

Ability to be a self-starter within your role scope

Excellent job attendance including ability to work in-person in our clinics (Our providers count on you.) required

Ability to commit to at least 1 year in role (2+ is ideal) required

Ability to work approximately 40-45 hours per week during clinic hours (full time position) with predictable hours and break times required

Compliance with hospital and Oak Street Health policies, including HIPAA required

US work authorization required

Behaviors

We strive for team members who represent our service standards and are :

Competent

Dependable

Inclusive

Seamless

Someone who embodies being 'Oaky'

3 days ago
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