Clinical Documentation & Information Specialist

Clinical Documentation & Information Specialist

Full-Time | Trillium Family Services
Location Requirement: Must reside in Oregon or Washington
Pay Range: $21.35 – $23.49/hour, depending on experience

Position Summary

Trillium Family Services is seeking a detail-oriented and collaborative Clinical Documentation & Information Specialist to support clinical documentation integrity, information management, and compliance functions across the organization. This role plays a vital part in ensuring clinical documentation and related records meet organizational, regulatory, and payer standards for accuracy, completeness, and appropriate use.

The Specialist may be assigned primary responsibilities within Clinical Documentation Integrity (CDI), Release of Information (ROI), or Compliance functions, while maintaining shared responsibilities across all areas. The ideal candidate will possess strong analytical skills, excellent communication abilities, and a commitment to maintaining confidentiality and compliance standards.

Essential Duties & Responsibilities

Clinical Documentation Integrity & Compliance

• Conduct real-time, retrospective, and event-driven reviews of clinical documentation and related records to ensure alignment with organizational standards, medical necessity requirements, coding standards, and regulatory expectations.
• Identify inconsistencies, unclear entries, or documentation gaps and initiate appropriate follow-up actions, including documentation queries when needed.
• Support corrective action planning and track improvements through follow-up reviews.
• Contribute to the development and refinement of documentation standards, workflows, and organization-wide quality and compliance initiatives.

Information Management & Reporting

• Track and monitor key performance and compliance metrics, including:
  • Documentation accuracy
  • Query response rates
  • Capture rates
  • Release timeliness
  • Alignment with diagnoses, reporting standards, and disclosure requirements
• Support compliant release and use of information by ensuring documentation integrity, completeness, and appropriateness for disclosure in response to audits, legal requests, payer reviews, and regulatory inquiries.

Collaboration & Communication

• Collaborate with clinical, coding, Release of Information (ROI), and compliance teams to resolve documentation, coding, and information management issues.
• Communicate clearly and professionally to support timely issue resolution and operational consistency.
• Provide guidance to clinical, operational, and administrative teams regarding documentation standards, audit readiness, compliant information disclosure, and compliance expectations.

Regulatory & Professional Standards

• Ensure documentation and information practices adhere to organizational policies, payer guidelines, and applicable state and federal regulations.
• Maintain strict confidentiality and professional standards in all interactions involving patient information.
• Stay current with regulatory changes, audit trends, and industry best practices related to clinical documentation integrity, coding, and release of information.

Additional Responsibilities

• Perform other duties as assigned.

Supervisory Responsibilities

• None

Qualifications

Minimum Qualifications

• Understanding of clinical documentation improvement principles and standards
• Familiarity with state and federal regulations, payer requirements, and compliance standards
• Strong analytical, organizational, and communication skills
• High School Diploma or equivalent required
• Two years in a Health Information Management (HIM) college-level program preferred

Preferred Experience

• Experience in behavioral health or pediatric healthcare settings
• Experience conducting audits of clinical documentation for compliance, coding accuracy, and medical necessity
• Experience with electronic health record (EHR) systems and coding software

Certificates, Licenses & Registrations

• Current driver’s license for state of residence
• Driving record acceptable by agency standards
• When authorized to use a personal vehicle for agency business, employee must maintain personal automobile insurance

Job Knowledge & Skills

• Ability to operate within established office procedures and organizational policies
• Knowledge of applicable federal, state, and local laws and regulations
• Ability to handle highly sensitive and confidential patient information
• Strong computer skills, including:
  • Word processing
  • Spreadsheets
  • Data entry
  • Electronic health record systems
• Strong organizational and customer service skills
• Excellent written, verbal, and phone communication skills
• Ability to work independently and collaboratively within a team environment
• Knowledge of medical terminology

Compensation & Benefits:

• Full-time 40 hours per week schedule.
• Comprehensive employer-paid healthcare benefits for eligible employees
• 401k with 6% match
• Generous vacation and sick leave
• A supportive team environment dedicated to equity, compassion, and high-quality care.

Why Join Trillium Family Services?

At Trillium Family Services, we are dedicated to improving the lives of children, families, and communities through compassionate behavioral health services. We value collaboration, integrity, and professional growth, and we are committed to fostering a supportive and inclusive workplace.

If you are ready to make a meaningful impact in the lives of children and families—and grow your career along the way—we’d love to hear from you.

To take a behind-the-scenes look at our programs please visit our website at www.trilliumfamily.org/.

Create a meaningful impact in the lives of others! Your journey to making a difference with Trillium Family Services starts now!

Pay Equity:  Please be advised that the pay range listed for this position is intended to provide general guidance on the earning potential for the role. However, actual compensation will be determined by the Oregon Equal Pay Law, which will take into account factors such as the candidate's relevant experience and education. Candidates should expect that initial offers will be made within the listed pay range and may not be at or near the top of the range.

For physical demands of position, including vision, hearing, repetitive motion, and environment, contact the HR department. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.

Consideration of candidates is ongoing, and position may close after 3 business days of posted opportunity.  

Please contact the Human Resources Department if you need accommodation to review the information and/or complete the application process.

Trillium Family Services is a drug-free workplace. All final applicants will be subject to a criminal record identification check pursuant to ORS 181.536.727.537 and agency policy. We are an Equal Opportunity Employer and Service Provider and support culturally linguistically diverse governance, leadership, and workforce.