Clinical Documentation & Information Specialist

Trillium Family Services • Corvallis, OR

7d • Remote

About The Position

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.

Requirements

• 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
• 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
• 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

Nice To Haves

• Two years in a Health Information Management (HIM) college-level program preferred
• 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

Responsibilities

• 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.
• Track and monitor key performance and compliance metrics, including documentation accuracy, query response rates, capture rates, release timeliness, and 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.
• 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.
• 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.
• Perform other duties as assigned.

Benefits

• Comprehensive employer-paid healthcare benefits for eligible employees
• 401k with 6% match
• Generous vacation and sick leave

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED