Medical Scribe

Role Description
The purpose of a Medical Scribe 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 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]

High school diploma

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]