Clinical Documentation Specialist

Benton County • Corvallis, OR

7d

About The Position

Benton County is currently in search of a Clinical Documentation Specialist to join our team! The Clinical Documentation Improvement Specialist supports accurate, complete, specific, and compliant clinical documentation across Health Services. This position reviews clinical documentation and related coding outcomes to identify opportunities for improvement in chart clarity, completeness, and consistency. The role works collaboratively with providers, coding and billing staff, operational leaders, and external vendors to strengthen documentation practices that support accurate code assignment, regulatory compliance, UDS reporting, risk adjustment, quality reporting, and revenue integrity. This position serves as an internal resource for documentation improvement and provides education, feedback, and process support to promote documentation that accurately reflects the patient’s condition, services provided, medical decision-making, and care outcomes.

Requirements

• Bachelor's degree from an accredited college or university in nursing, physiology, health information management or other related fields.
• 1 year of experience in clinical documentation improvement, medical coding, medical auditing, health information management, revenue cycle, quality review, or a closely related healthcare role required.
• An equivalent combination of education and experience may be accepted. Candidates must have at least 6 months of actual work experience to be considered as equivalent.
• Medical Records Coding certification; Certification of Coding Education Program (CCEP) or Certified Professional Coder (CPC) or ability to obtain within 6 months.
• Experience reviewing medical records for documentation quality, coding support, compliance, and/or billing accuracy required.
• Experience using Microsoft Office suite and electronic health record/practice management systems such as OCHIN Epic or similar systems required.
• Strong analytical skills and ability to interpret complex clinical documentation and communicate findings clearly and respectfully.
• Ability to work collaboratively with providers, operational leaders, external vendors, and non-clinical staff.
• Strong written and verbal communication skills, including ability to provide education and feedback in an effective and supportive manner.

Nice To Haves

• Clinical Documentation Improvement certification such as CCDS or CDIP preferred, or ability to obtain within 6 months.
• Minimum of two years of experience in clinical documentation improvement, medical coding, medical auditing, health information management, revenue cycle, quality review, or a closely related healthcare role required.
• Strong knowledge of CPT, HCPCS, ICD-10-CM, and documentation requirements in ambulatory care, community health center, and/or FQHC settings preferred.
• Knowledge of healthcare reimbursement, payer requirements, medical necessity, and the relationship between documentation, coding, quality reporting, and revenue integrity preferred.
• Knowledge of HIPAA privacy laws and confidentiality requirements related to protected health information.

Responsibilities

• Reviews clinical documentation and related coding outcomes to identify opportunities for improvement in chart clarity, completeness, and consistency.
• Works collaboratively with providers, coding and billing staff, operational leaders, and external vendors to strengthen documentation practices.
• Serves as an internal resource for documentation improvement.
• Provides education, feedback, and process support to promote documentation that accurately reflects the patient’s condition, services provided, medical decision-making, and care outcomes.

Benefits

• Generous time off
• 11 Paid Holidays
• 2 Floating Holidays
• 8 hours of vacation accrual every month
• Sick leave
• Vacation accrual increases with years of service.
• $0 Health Insurance Premium
• Medical, Dental and Vision - cover your eligible family members without additional premium.
• County contributes up to $1,900 per year to your Health Savings or Health Reimbursement account.
• Health Savings Account funds roll over from year to year.
• Dependents up to age 26 are covered.
• Generous employer paid contributions to retirement
• After 6 months of employment: The County makes a retirement contribution of 6% of your salary towards Oregon PERS.
• The County makes a deferred compensation 457b plan contribution of 1.5% of your salary.
• A free and award-winning wellness program
• Interactive and personalized approach focused on your whole health.
• Onsite and virtual seminars, wellness challenges and fun activities.
• Monetary incentives and cool prizes
• 100% employer-paid coverage for AD&D ($100,000), Life ($50,000), and Long-Term Disability coverage.
• Supplemental plans are available at reasonable rates.
• Two salary raises within your first year as long as performance is in good standing.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level