clinical documentation specialist

Rochester Regional Health

<div><p><b>SUMMARY</b></p><p>
The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.</p><p></p><p><b>
STATUS: Full-time</b></p><p><b>
LOCATION: Remote</b></p><p><b>
DEPARTMENT: Clinical Documentation
</b></p><p><b>SCHEDULE: Day shift</b></p><p></p><p><b>
ATTRIBUTES</b></p><ul><li>Ability to learn/develop the skills necessary to perform the CDS role</li><li>Organizational, analytical, writing and interpersonal skills</li><li>Dependable, self-directed and pleasant</li><li>Critical thinking, problem solving and deductive reasoning skills</li><li>Knowledge of Pathophysiology and Disease Process</li><li>Basic Computer skills &ndash; familiarity with Windows based software programs</li><li>Knowledge of regulatory environment</li><li>Understand and support CDS documentation strategies (upon completion of training)</li><li>Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)</li><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li><li>For Skilled Nursing Facility Only:</li></ul>
a. Understand Medicare Part A guidelines<br>
b. Understand the current FY SNF PPS Final Rule<br>
c. Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings<br>
d. Understand the MDS Resident Assessment Instrument (RAI) Manual<br>
e. Ability to use the CMS PDPM Calculator Tool<div><br>
Minimum Qualifications:<br>
<ul><li>3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.</li><li>Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.</li><li>Previous CDS experience preferred</li></ul></div><ul><li>For Skilled Nursing Facility Only:</li></ul>
a. 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility<br>
b. Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.<br>
OR a degree in Health Information Management (Associate&rsquo;s Degree with RHIT; Bachelor&rsquo;s Degree with RHIA)<p><br>
Required Licensure/Certification:<br>
RN, PA, NP, MBBS or MD prepared candidates.<br>
If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire.</p><p>
For Skilled Nursing Facility Only:<br>
Valid RN or LPN license, or other applicable professional license, or RHIT, or RHIA</p><p>
Rochester General Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran</p><p></p><p><b>
RESPONSIBILITIES</b></p><ul><li><ul><li>Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality</li><li>Accurate and timely record review</li><li>Recognize opportunities for documentation improvement</li><li>Formulate clinically credible documentation clarifications</li><li>Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety</li><li>Effective and appropriate communication with physicians</li><li>Provides education to members of the patient care team regarding the CDS process.</li><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications</li><li>Actively participate in Team Meetings</li><li>Manage multiple priorities</li><li>Communicates with HIM staff and resolves discrepancies</li><li>Accurate input of data into department software</li><li>For Skilled Nursing Facility Only:</li></ul>
a. Utilize the ICD-10-CM Official Guidelines for Coding &amp; Reporting and their application in the long-term healthcare setting.<br>
b. Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.<br>
c. Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.</li></ul><p></p><p>
#RRHProfessional26</p><p></p><p><b>
EDUCATION:</b></p><p></p><p><b>
LICENSES / </b><b>CERTIFICATIONS:</b></p>
RN - Registered Nurse - New York State Education Department (NYSED)<p></p><p><b>
PHYSICAL REQUIREMENTS:</b></p>
S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.<p></p><p><b>
For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.</b><b>
</b></p><p></p><p><b>Any physical requirements reported by a prospective employee and/or employee&rsquo;s physician or delegate will be considered for accommodations.
</b></p><p></p><p><b>PAY RANGE:</b></p>
$78,000.00 - $95,000.00<p></p><div><div><div><div><div><div><div><p><b>
CITY:</b></p></div></div></div></div></div></div></div>
Rochester<p></p><div><div><div><div><div><div><div><p><b>
POSTAL CODE:</b></p></div></div></div></div></div></div></div>
14621<p></p><p><b><i>
The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.</i></b></p><p></p><p><b>
Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.</b></p></div>

Clinical Documentation Specialist

SMP Health

<p></p><div><div><div><div><div><div><div><h2 class="jobSectionHeader">WHAT YOU CAN EXPECT<b> from</b></h2><h2 class="jobSectionHeader"><b>
SMP Health &ndash; St. Aloisius</b></h2></div></div><h6 class="jobSectionHeader"><b>
Below is a list of available benefits for those working 15 hours or more per week:</b></h6></div></div></div></div><div></div><div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
HEALTH INSURANCE</b></h6></p><div><div><div>
Employees working 60 hours or more in a 2-week pay period are eligible for health insurance. Please see your Human Resources Specialist regarding plan benefits and enrollment criteria.</div></div></div></div></div></div><div></div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
HEALTH SAVINGS ACCOUNT (HSA)</b></h6></p><div><div><div>
SMP Health &ndash; St. Aloisius provides a high deductible health care plan with an HSA. Please see your Human Resources Specialist regarding plan benefits and enrollment criteria.</div></div></div></div></div></div></div><div></div><div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
FLEXIBLE SPENDING ACCOUNTS</b></h6></p><div><div><div>
If you do not have an HSA, you might consider a Flexible Spending Account, which provides you with the opportunity through payroll deduction to set aside a portion of what would have been taxable income and deposit the money into a Personal Reimbursement Account.</div></div></div></div></div></div><div></div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
RETIREMENT AND THE 403(b) SAVINGS PLAN</b></h6></p><div><div><div>
A 3% contribution is provided by SMP Health &ndash; St. Aloisius at no cost to the employee. The 3% contribution is based on an employee&rsquo;s gross earnings after one year of service. To meet eligibility requirements, employees must complete 1,000 hours of service within a 12-month period, and the employee must be 21 years of age.</div></div></div></div></div></div></div><div></div><div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
SHORT TERM DISABILITY PROGRAM</b></h6></p><div><div><div>
A serious medical condition can result in the loss of income that is important to you. The disability plans administered by SMP Health &ndash; St. Aloisius will help to provide protection during such an event.</div></div></div></div></div></div><div></div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
SERVICE AWARDS</b></h6></p><div><div><div>
In recognition of service to SMP Health &ndash; St. Aloisius, you will receive recognition after the following continuous years of service: 5, 10, 15, 20, etc. Each milestone in your service at SMP Health &ndash; St. Aloisius will be recognized by your facility.</div></div></div></div></div></div></div><div></div><div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
EMPLOYEE ASSISTANCE PROGRAM (EAP)</b></h6></p><div><div><div>
Through CHI St. Alexius Health (our Employee Assistance Program), SMP Health &ndash; St. Aloisius provides a valuable benefit to you by making available independent and objective counseling or referral for marital, family, legal, financial, emotional, and chemical dependency problems.</div></div></div></div></div></div><div></div><div><div><div><p><h6 class="jobSectionHeader"><b><br>
HOLIDAYS</b></h6></p><div><p>
New Year&rsquo;s Day (holiday pay begins Midnight on New Year&rsquo;s Eve)<br>
Easter Sunday<br>
Memorial Day<br>
Independence Day<br>
Labor Day<br>
Thanksgiving Day<br>
Christmas Day (holiday pay begins at 5 p.m. on Christmas Eve)</p></div></div></div></div></div></div>
<br><div><div><div><b>Medical Scribe/Clinical Documentation Specialist</b></div><div> PT</div><div> The Medical Scribe / Clinical Documentation Specialist supports providers by documenting patient visits in real time and keeping medical records accurate and up to date.
<br>
<br>
This is a part-time, on-site role that works directly alongside providers during appointments, entering notes, updating charts, and assisting with orders in the electronic health record system. The position also helps organize lab results and other information to keep the clinic running smoothly. This allows providers to focus more on patient care while ensuring documentation is complete.
<br>
<br>
The ideal candidate is organized, detail-oriented, and able to work efficiently in a fast-paced setting. Strong typing skills and clear communication are important, and while a medical background is helpful, it is not required.</div></div></div><div></div>

Medical Scribe/Clinical Documentation Specialist

Vetter Senior Living

<div>
 Added
 <br/>
 <br/>
 4/6/2026 10:01 AM
 <br/>
 <br/>
 <strong>
  Company
  <br/>
  <br/>
 </strong>
 Vetter Senior Living
 <br/>
 <br/>
 Website
 <br/>
 <br/>
 www.vetterseniorliving.com
 <br/>
 <br/>
 Job Title
 <br/>
 <br/>
 ICD 10 Nurse Specialist (RN)
 <br/>
 <br/>
 City
 <br/>
 <br/>
 Elkhorn
 <br/>
 <br/>
 Type
 <br/>
 <br/>
 Full Time
 <br/>
 <br/>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 At
 <strong>
  Vetter Senior Living
 </strong>
 , our Mission is
 <em>
  Dignity in Life
 </em>
 . We believe every person deserves to feel respected, supported, and cared for ? and that starts with the people who serve them. We?re currently seeking a
 <strong>
  Registered Nurse (RN)
 </strong>
 with a passion for accuracy, education, and collaboration to join our team as an
 <strong>
  ICD-10 Nurse Specialist
 </strong>
 , based in our
 <strong>
  Elkhorn, Nebraska home office
 </strong>
 .
 <br/>
 <br/>
 This position plays a key role in supporting
 <strong>
  Quality Care
 </strong>
 and
 <strong>
  Stewardship
 </strong>
 by ensuring accurate diagnosis coding that reflects residents? true clinical picture, supports regulatory compliance, and enables appropriate reimbursement. Through strong relationships, auditing, and education, the ICD-10 Nurse Specialist serves as a trusted resource across our communities.
 <br/>
 <br/>
 <strong>
  The ICD-10 Nurse Specialist Will
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Serve as the ICD-10 subject matter expert for Vetter Senior Living operations
  </li>
  <li>
   Review and audit:
  </li>
  <ul>
   <li>
    Skilled and non-skilled admissions
   </li>
   <li>
    Diagnosis sheets and physician orders
   </li>
   <li>
    Therapy diagnosis documentation
   </li>
  </ul>
  <li>
   Ensure ICD-10 diagnoses are accurate, supported, and properly sequenced
  </li>
  <li>
   Identify trends contributing to billing errors, RTPs, or denials
  </li>
  <li>
   Provide targeted education and coaching to clinical and interdisciplinary teams
  </li>
  <li>
   Support annual and interim ICD-10 updates and documentation expectations
  </li>
  <li>
   Partner closely with Financial Services and Billing to support accurate reimbursement
  </li>
  <li>
   Promote collaboration, accountability, and process improvement across departments
  </li>
  <li>
   Work from the Elkhorn home office
  </li>
  <li>
   Travel up to 10% of the time
  </li>
  <li>
   Model the Mission, Vision and Values of Vetter Senior Living at all times
   <br/>
  </li>
 </ul>
 Additional Information
 <br/>
 <br/>
 <strong>
  Qualified Candidates Will
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Have an active Registered Nurse (RN) license
  </li>
  <li>
   Possess a strong working knowledge of:
  </li>
  <ul>
   <li>
    ICD-10 diagnosis coding
   </li>
   <li>
    Skilled nursing and senior living operations
   </li>
   <li>
    Medicare reimbursement and billing processes
   </li>
  </ul>
  <li>
   Have the ability to review clinical documentation with attention to detail
  </li>
  <li>
   Possess strong written and verbal communication skills
  </li>
  <li>
   Be comfortable educating and supporting diverse teams
  </li>
  <li>
   Have a willingness to work on-site in Elkhorn and travel up to 10% as needed
  </li>
  <li>
   Be aligned with the Mission, Vision and Values of Vetter Senior Living
   <br/>
  </li>
 </ul>
 How to Apply
 <br/>
 <br/>
 <strong>
  Vetter Senior Living Offers
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Meaningful work that directly supports resident care and clinical integrity
  </li>
  <li>
   A mission-driven culture rooted in Dignity in Life
  </li>
  <li>
   Collaboration, respect, and trust across teams
  </li>
  <li>
   The opportunity to make a system-wide impact
  </li>
  <li>
   A supportive environment that values expertise, learning, and continuous improvement
   <br/>
   <br/>
  </li>
 </ul>
 If you?re an RN who values accuracy, education, and building strong relationships ? and you want your work to truly make a difference ? we?d love to talk with you.
 <br/>
 <br/>
 <strong>
  Apply On Our Websit
  <br/>
  <br/>
 </strong>
 https://myjobs.adp.com/vhshomeoffice/cx/job-details?reqId=5001189371006
</div>


ICD 10 Nurse Specialist (RN)

Neurology Consultants Central Florida

<p><b>Clinical Specialist / Medical Scribe (Neurology)</b></p><p>Neurology Consultants of Central Florida (NCCF)</p><p>Kissimmee, FL (In-Person)</p><p><b>Overview</b></p><p>Neurology Consultants of Central Florida is seeking a Clinical Specialist / Medical Scribe to work directly with an attending neurologist in both clinic and hospital settings.</p><p>This role is designed for medical school graduates seeking a serious, hands-on clinical experience prior to residency or advanced medical students (MS3/MS4).</p><p>This is not a medical assistant or passive shadowing role.</p><p>Candidates will be expected to engage actively in patient care, documentation, and clinical workflow, developing the skills and judgment expected at the next level of training.</p><p><b>Why This Role Stands Out</b></p><ul><li>Direct, daily collaboration with an experienced attending neurologist</li><li>Active participation in patient care (histories, exams, assessment documentation)</li><li>Exposure to both outpatient and hospital neurology</li><li>High-volume clinical environment with real responsibility</li><li>Close mentorship with individualized feedback</li></ul><p>High-performing candidates may receive a detailed, experience-based letter of recommendation reflecting clinical ability, work ethic, and growth over time.</p><p><b>Responsibilities</b></p><ul><li>Prepare detailed patient summaries ahead of clinic</li><li>Review and organize labs, imaging, and diagnostic results in EMR</li><li>Work alongside physician during patient visits (histories, exams, documentation)</li><li>Accurately document encounters in real time</li><li>Support clinic operations and patient care coordination</li><li>Assist in mentoring rotating medical students</li></ul><p><b>Qualifications</b></p><p>Required:</p><ul><li>Medical school graduate OR completion of at least 2 years of medical school</li></ul><p>Strongly Preferred:</p><ul><li>MS3/MS4 or recent graduate actively preparing for residency</li><li>Demonstrated ability to take initiative in a fast-paced clinical setting</li><li>Prior clinical or scribing experience</li></ul><p>Additional Preferred:</p><ul><li>USMLE scores</li><li>ECFMG certification (for IMGs)</li></ul><p>Core Competencies:</p><ul><li>Strong clinical reasoning and attention to detail</li><li>Clear, concise medical documentation</li><li>Professionalism and patient-centered communication</li><li>Ability to anticipate workflow needs and operate with minimal supervision</li></ul><p><b>Position Details</b></p><ul><li>Start: April 2026</li><li>Commitment: 1 year preferred</li><li>Schedule: Full-time or part-time (flexibility for exams/interviews)</li><li>Location: Kissimmee, FL (in-person)</li></ul><p><b>About the Practice</b></p><ul><li>40+ years of physician experience</li><li>Long-standing patient relationships</li><li>Hospital affiliations: AdventHealth Kissimmee, HCA Florida Osceola, Orlando Health St. Cloud</li><li>Academic involvement with UCF College of Medicine and St. Matthew&rsquo;s University</li></ul><p><b>How to Apply</b></p><p>Submit resume and cover letter or ERAS application to:<br/>neurologyconsultantsflorida@gmail.com</p><p>Indicate full-time or part-time preference</p><p><b>Additional Information</b></p><ul><li>No visa sponsorship available</li><li>Ideal for candidates seeking a structured, high-responsibility bridge to residency</li></ul><p><b>Application Note</b></p><p>In your email, briefly describe your clinical experience and what you are looking to gain from this role.</p><p>Job Types: Full-time, Part-time</p><p>Pay: $17.00 - $19.00 per hour</p><p>Work Location: In person</p>

Medical Graduate/Student (Clinical Assistant / Medical Scribe Neurology)

MyMichigan Health

<div>
 <strong>
  Summary
  <br/>
  <br/>
 </strong>
 The coding specialist, utilizing the clinical documentation management program and clinical knowledge, analyzes inpatient and outpatient medical records for completeness of documentation, contacting the appropriate provider for additional documentation if needed. Accurate diagnosis and procedure codes are then assigned based on the documentation in the medical record, which directly impacts the appropriate DRG assignment for reimbursement. Critical data elements are abstracted by the Coding specialist on all inpatient discharges. This information is used by the organization for decision making.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <strong>
  (60%)*
 </strong>
 Assigns accurate ICD-CM diagnosis and procedure codes and CPT codes in a timely manner for all appropriate encounters and ensures appropriate DRG assignment based on the clinical documentation within the medical record by using CMS and American Hospital Guidelines and following AHIMA code of ethics.
 <br/>
 <br/>
 <strong>
  (30%)*
 </strong>
 Utilizes clinical knowledge to interact with the Clinical Documentation Specialists and physicians/providers on a daily basis to assist in improving documentation within the medical record; to accurately reflect the severity of illness and level of care provided.
 <br/>
 <br/>
 <strong>
  (10%)*
 </strong>
 Demonstrates willingness to participate in continuing education to enhance coding knowledge.
 <br/>
 <br/>
 <strong>
  Other Duties And Responsibilities
  <br/>
  <br/>
 </strong>
 Meets established productivity guidelines.
 <br/>
 <br/>
 Other duties as assigned.
 <br/>
 <br/>
 MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows.
 <br/>
 <br/>
 An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
 <br/>
 <br/>
 Certifications and Licensures
 <br/>
 <br/>
 E/M CODER: CPC, CCS, CCSP, RHIT, OR RHIA
 <br/>
 <br/>
 Effective October 1, 2013, new hires must be RHIA or RHIT eligible and successfully complete the certification exam within six (6) months of hire and maintain the certification to meet the requirements of the position.
 <br/>
 <br/>
 FINGERPRIN: Fingerprinting
 <br/>
 <br/>
 Required Education
 <br/>
 <br/>
 Associates degree is required
 <br/>
 <br/>
 Other Information
 <br/>
 <br/>
 <strong>
  Experience, Training And Skills
  <br/>
  <br/>
 </strong>
 Coding experience from an AHIMA approved internship required or successfully completed an independent study program offered by AHIMA.
 <br/>
 <br/>
 Knowledge of medical terminology and anatomy.
 <br/>
 <br/>
 Written, oral, organizational and interpersonal skills needed to communicate successfully.
 <br/>
 <br/>
 <strong>
  Physical/Mental Requirements And Typical Working Conditions
  <br/>
  <br/>
 </strong>
 Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
 <br/>
 <br/>
 Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
 <br/>
 <br/>
 Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
 <br/>
 <br/>
 Overall vision and hearing is necessary with or without assisted device(s).
 <br/>
 <br/>
 Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
 <br/>
 <br/>
 Some exposure to blood borne pathogens and other potentially infectious material
 <br/>
 <br/>
 Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
 <br/>
 <br/>
 Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
 <br/>
 <br/>
 Physical Demand Level:
 <strong>
  Sedentary.
 </strong>
 Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.
</div>


Coder II

Oak Street Health, part of CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Title: </b>Medical Scribe</p><p></p><p><b>
Company: </b>Oak Street Health</p><p></p><p><b>
Role Description:</b></p><p></p><p>
The purpose of a Clinical Informatics Specialist (CIS or 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.</p><p></p><p>
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.</p><p></p><p>
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.</p><p></p><p><b>
Responsibilities:</b></p><ul><li>
Documenting Patient Encounters ~ 80%<ul><li>
Joining the provider in the exam room to observe patient visits</li><li>
Documenting patient encounters in a structured note, including the history of the present illness, assessment, plan, and physical exam</li><li>
Assigning appropriate CPT and ICD-10 codes</li><li>
Preparing After Visit Summaries</li><li>
Consulting with provider to ensure accurate and specific documentation</li></ul></li><li>
Clinical Documentation Improvement ~ 10%<ul><li>
Requesting and reviewing medical records</li><li>
Leveraging Oak Street's population health tools to support clinical documentation improvement</li><li>
Preparing for and supporting Daily Huddles and Clinical Documentation Reviews</li><li>
Consulting with provider on clinical documentation opportunities</li></ul></li><li>
Administrative support for your provider and care team ~ 10%<ul><li>
Placing orders and referrals</li><li>
Addressing tasks</li><li>
Supporting the care team with additional responsibilities related to clinical documentation</li></ul></li><li>
Other duties as assigned</li></ul><p></p><p><b>
What we're looking for</b></p><p></p><p><b>
Knowledge</b></p><ul><li>
Knowledge of medical terminology and common medications, either from a pre-medical degree or prior clinical experience [required]</li><li>
Prior clinical experience, including shadowing and/or volunteering [strongly preferred]</li><li>
Prior scribe or transcription experience [preferred but not required]</li></ul><p></p><p><b>
Skills</b></p><ul><li>
Advanced listening and communication skills [required]</li><li>
Strong computer literacy and ability to learn new technical workflows [required]</li><li>
Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve [required where indicated]</li></ul><p></p><p><b>
Abilities</b></p><ul><li>
Ability to adapt to new workflows and to quickly learn new concepts and skills [required]</li><li>
Ability to type 70+ words per minute [strongly preferred]</li><li>
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]</li><li>
Ability to be a self-starter within your role scope</li><li>
Excellent job attendance including ability to work in-person in our clinics (Our providers count on you.) [required]</li><li>
Ability to commit to at least 1 year in role (2+ is ideal) [required]</li><li>
Ability to work approximately 40-45 hours per week during clinic hours (full time position) with predictable hours and break times [required]</li><li>
Compliance with hospital and Oak Street Health policies, including HIPAA [required]</li><li>
US work authorization [required]</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$17.00 - $31.30<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
We anticipate the application window for this opening will close on: 10/01/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Float Medical Scribe

Smilow Cancer Hospital

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 <strong>
  Overview
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 </strong>
 To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
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 As a member of the Center for Population Health, the HCC Documentation Lead (RN), while incorporating the role of the HCC Documentation Specialist, is expected to demonstrate a higher level of comprehension and expertise in HCC Documentation integrity and is responsible for overall coordination of HCC Documentation specialists, provide procedural guidance, and assumes responsibility for achieving desired results in conjunction with leadership and program manager support. The HCC Documentation Lead will serve as a partner and subject matter expert on HCC coding and documentation for clinicians who are a part of our Clinically Integrated Network (CIN), Yale New Haven Health Clinical Affiliates. The position is responsible for leading the efforts related to clinician education regarding documentation opportunities through appropriate channels on an ongoing basis. Working with leadership and staff, the HCC Documentation Lead will contribute to content development and ongoing documentation; participates and organizes projects related to performance improvement.
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 EEO/AA/Disability/Veteran
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  Responsibilities
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   1. Pre Visit Support
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    1.1 Provide support to clinicians through patient record reviews in advance of patient visits, focused on recapture of HCCs and other potential chronic diagnoses, evaluating new HCC diagnosis capture opportunities based on appropriate clinical indicators and validation of data-driven suspect diagnoses.
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    1.2 Provides second-level reviews and assists with audits of documentation for quality and accuracy assurance, as needed. Serves as a resource for team to ensure efficient query response .
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    1.3 Organizes special projects. Acts as a resource to direct the project team. Involved in initiatives such as clinician engagement (i.e. response rate) and administration engagement (i.e. KPI and metric development)
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    1.4 Functions as a subject matter expert and actively participates in department meetings as a problem solver. Expert in workqueue and workflow management.
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    1.5 Ensures efficiency and productivity of the processes and workflows of team , participating in orientation of new hires, reporting issues to leadership, and getting involved in committees / projects.
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    1.6 Identifies opportunities for performance improvement through evaluation of trends and proposes potential solutions.
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    1.7 Partners with coding and billing teams to ensure completeness of supporting documentation, as appropriate.
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    2. Clinician Education
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    2.1 Interact with clinicians regarding questions about pre-visit documentation needs or suspect diagnoses
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    2.2 Educate clinicians and internal staff on HCC documentation and guidelines using a multi -model approach, including 1:1, group and pre-recorded sessions in coordination with other members of the Center for Population Health
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    2.3 Works with other members of the Center for Population Health to develop educational content.
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    2.4 Provide ongoing team learning opportunities through sharing of professional knowledge.
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    3. Staff oversight
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    3.1 Provide day to day guidance and support to HCC Documentation Specialists, clarifying priorities and role expectations.
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    3.2 Identify and assist in the development of skill sets through regular feedback channels for individual team members.
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    3.3 Participate in annual performance reviews
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    4. Performs other duties as assigned or directed.
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    4.1 Performs other duties as assigned that support the program to meet program and organizational goals.
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  Qualifications
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 </strong>
 EDUCATION
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 Registered Nurse with active RN required, BSN preferred. CCS-P, CPC, CRC, or other coding credential required.
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  Experience
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 Experienced HCC Documentation Specialist with minimum of three (3) years experience in role. At least three (3) years of recent acute care nursing experience required; ICU experience preferred. Previous clinical leadership experience preferred.
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 LICENSURE
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 RN license required. CCS-P, CPC, CRC, or other coding credential required.
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  Special Skills
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 Excellent communication and organizational skills. Adaptability to a wide variety of interpersonal encounters with the care team. Comprehensive understanding in use of medical record to extract data. Computer PC literacy required. Must be able to work collaboratively and independently. Must be flexible with responsibilities in order to meet departmental needs. Must have keen eye to detail. Ability to develop and maintain supportive, collaborative relationships with physicians and other clinical professionals. Ability to track activities and communications across multiple physician services and forums.
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 PHYSICAL DEMAND
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 Ability to communicate clearly and confidently to clinicians the program goals and documentation opportunities using email, in personal communication, telephone or other written and electronic forms of communication. Primarily remote position, however occasional on site participation in meetings, trainings and conducting education sessions may be required on ad hoc basis.
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 YNHHS Requisition ID
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 160356
</div>


HCC Clinical Documentation Lead (RN)

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