[Hiring] Clinical Documentation & Information Specialist @Trillium Family Services

Role Description

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.

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

Requirements

• 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

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