Clinical Documentation & Information Specialist

Trillium Family Services • Portland, OR

17d • $21 - $23 • Hybrid

About The Position

Trillium Family Services is hiring a detail-oriented, collaborative Clinical Documentation & Information Specialist to support clinical documentation integrity, information management, and compliance across the organization. The role helps ensure clinical documentation and related records meet organizational, regulatory, and payer standards for accuracy, completeness, and appropriate use. The Specialist may focus primarily on Clinical Documentation Integrity (CDI), Release of Information (ROI), or Compliance while retaining responsibilities across all areas. The position is full-time, 40 hours per week, and hybrid in the Portland area. Employees must reside in Oregon or Washington. The listed pay range is $21.35–$23.49 per hour, depending on experience.

The role conducts documentation reviews, identifies gaps and inconsistencies, supports corrective actions, monitors performance and compliance metrics, and helps ensure compliant information disclosure. It works collaboratively with clinical, coding, ROI, and compliance teams; provides guidance on documentation standards and audit readiness; and maintains confidentiality and professional standards. The role has no supervisory responsibilities.

Trillium Family Services provides behavioral health services to children and families and describes its workplace as supportive and inclusive, with an emphasis on collaboration, integrity, equity, compassion, high-quality care, and professional growth. Final applicants are subject to a criminal record identification check under applicable law and agency policy.

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.
• Maintain personal automobile insurance when authorized to use a personal vehicle for agency business.
• 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, and 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.
• Must reside in Oregon or Washington.

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 for alignment with organizational standards, medical necessity requirements, coding standards, and regulatory expectations.
• Identify inconsistencies, unclear entries, and documentation gaps, and initiate follow-up actions, including documentation queries when needed.
• Support corrective action planning and track improvements through follow-up reviews.
• Contribute to developing and refining documentation standards, workflows, and organization-wide quality and compliance initiatives.
• Track and monitor 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 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.
• 401(k) with 6% match.
• Generous vacation and sick leave.
• Supportive team environment dedicated to equity, compassion, and high-quality care.
• Supportive and inclusive workplace with an emphasis on professional growth.

What This Job Offers

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