Job Description

• The purpose of a Clinical Informatics Specialist 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 Product 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.

• 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.

• Requesting and reviewing medical records.
• Leveraging client'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.

• Placing orders and referrals.
• Addressing tasks.
• Supporting the care team with additional responsibilities related to clinical documentation.

• 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].

• 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].

• Ability to adapt to new workflows and to quickly learn new concepts and skills [required].
• Ability to type 70+ words per minute [strongly preferred] - client include typing score at top of resume.
• 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 Product.
• 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 Client policies, including HIPAA [required].
• US work authorization [required].

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