Behavioral Health Clinical Documentation Specialist (BHCDS)

Job Description

Job Description

Description:

Odyssey House is looking for a Full-Time Behavioral Health Clinical Documentation Specialist (BHCDS)!

The Behavioral Health Clinical Documentation Specialist is a specialized behavioral health role within Admissions

responsible for developing the majority of the factual biopsychosocial record used by licensed clinicians to

complete diagnostic assessment, ASAM determination, medical necessity, suicide risk review, and treatment

planning. Reporting to the Admissions Director, the BHCDS conducts structured, trauma-informed interviews;

documents detailed client-reported and record-supported history; completes assigned BestNotes structured fields;

reconciles source information; identifies discrepancies and escalation needs; administers designated screening

tools when trained and permitted; and prepares a complete, organized record for LMHT review. This position is

not a case manager, intake coordinator, or therapist and does not independently perform functions requiring

licensed clinical judgment.

Job Location: Salt lake City

Compensation: $57,000 annually

 

Benefits Package: Equals to approximately $22,000. Includes medical, dental, life, and disability insurance, flexible spending account, retirement plan, paid leave, employee assistance program, and education assistance. 

Health and Welfare Benefits

• Health Insurance: Comprehensive medical, dental, vision, FSA, and long-/short-term disability coverage.
• 403(b) Retirement Plan: Immediate participation available; 100% employer match up to 6% after 1 year of service.
• Paid Time Off (PTO): Accrue up to 35 paid days off per year (with increased accrual rates after 1 year).
• Sick Leave Rollover: Convert half of your unused accrued sick time into extra vacation days at year-end.
• Sabbatical Program: Paid extended leave rewarded after 5 years of service.
• Employee Assistance Program (EAP): Confidential 24/7 support for mental health, financial advice, and personal well-being.

Perks

• Tuition Reimbursement: Up to $9,000 per year available for approved programs (subject to eligibility requirements).
• Continuing Education: Opportunities for paid training and professional development, subject to manager approval and eligibility.
• On-Demand Pay: Access earned wages before payday via our payroll provider, Paylocity (managed directly through Paylocity; terms apply).
• Transit Pass: Free UTA pass provided for your daily work commute.
• Monthly Incentives: Regular performance awards and team recognition.
• Casual Work Environment: Relaxed, casual dress code and workplace culture.

Responsibilities & Duties

To support accurate, timely, and clinically useful admission assessments, the BHCDS is responsible for factual

biopsychosocial interviewing, clinical-record development, source reconciliation, designated screening

administration, documentation integrity, records and collateral preparation, and immediate escalation of safety or clinical concerns.

Biopsychosocial Assessment & Documentation

• Conduct the majority of the nonlicensed biopsychosocial interview and document factual information in a clear, objective, source-supported manner.
• Gather detailed substance-use history, including age of first use, problematic onset when reported, amount, frequency, route, pattern, last use, tolerance, cravings, withdrawal history, overdose history, IV/needle history, prior detox, prior treatment, longest recovery period, relapse/return-to-use history, and MAT/MOUD history as reported or documented.
• Gather prior mental health and SUD treatment history and previous diagnoses as historical information only, without independently establishing or validating a current diagnosis.
• Gather factual medical, medication, surgical, dental, nutrition, sleep, provider, and other relevant health-history information and route clinical or medical concerns appropriately.
• Gather factual trauma history, family history, relationships, housing, employment, education, legal status, probation/parole/court involvement, transportation, finances, supports, recovery environment, culture, spirituality, values, and other social determinants of health.
• Complete assigned BestNotes tables, checkboxes, discrete fields, and factual narrative sections using supported client report and source records.
• Prepare the record for LMHT review by ensuring assigned factual sections are complete, internally consistent, and traceable to source information.

Clinical Documentation Integrity

• Request, obtain, upload, label, and organize prior treatment records, hospital records, medication information, psychiatric evaluations, prior Odyssey House records, correctional/legal records, referral information, and other collateral.
• Compare client report with available collateral and records, identify discrepancies, and route clinically meaningful contradictions to the LMHT for resolution rather than independently resolving them.
• Perform nonclinical documentation-quality review for assigned BestNotes fields, source consistency, dates, supporting records, and completion status.
• Maintain documentation that is timely, accurate, objective, organized, and ready for clinical review and audit.

Screening & Safety Support

• Administer and document the C-SSRS when permitted by Odyssey House policy, training, and competency, with real-time clinician review as required by policy.
• Immediately escalate positive, ambiguous, or concerning C-SSRS findings for LMHT clinical review and risk determination.
• Complete SMI/SED structured screening or scoring mechanics when permitted by policy and training and route required interpretation or classification decisions to the LMHT.
• Recognize and immediately escalate signs of acute withdrawal, overdose risk, suicidal or homicidal risk, psychosis, severe impairment, abuse, exploitation, violence, or other urgent concerns according to Odyssey House policy.

Expectations

• Assigned factual BPS and structured fields are completed before LMHT clinical review whenever workflow allows.
• Documentation is accurate, objective, source-supported, and requires minimal correction.
• Clinical or safety concerns are escalated immediately through the appropriate chain of command.
• Records and collateral are obtained, organized, and clearly tied to source and date.
• BHCDS maintains clear scope boundaries and does not independently complete the MSE, DSM diagnosis, ASAM risk or level-of-care determination, medical necessity, suicide-risk formulation or disposition, treatment plan/PGOM, or psychotherapy.
• Admissions workflow is supported during high-volume admission periods and intake events.
• BHCDS contributes to measurable reduction in therapist time spent on nonlicensed history gathering and chart-development tasks.

Responsibilities

• Reports to and works closely with the Admissions Director to ensure admission workflow, assessment support, and documentation expectations are met.
• Collaborates with LMHTs to ensure the factual record is sufficiently developed for clinical formulation and final assessment completion.
• Works collaboratively with medical, nursing, utilization review, justice-services, and program staff when records or factual information are needed for the admission record.
• Participates in training, supervision, quality-improvement efforts, intake events, and other duties assigned within role scope.
• Maintains HIPAA, 42 CFR Part 2, confidentiality, professional-boundary, documentation, and information-security standards.

Requirements:

Qualifications

• Bachelor's degree in Social Work, Psychology, Behavioral Science, Human Services, Family Studies, Sociology, Criminal Justice, or a closely related field preferred.
• Non degree experience may be considered with at least one year of directly relevant behavioral health, SUD, residential treatment, corrections, assessment support, or complex social-service experience.
• Experience conducting structured psychosocial, behavioral health, SUD, or social-service interviews strongly preferred.
• Experience with behavioral health EHR documentation, clinical records, or complex source-based documentation preferred.
• BestNotes experience preferred.
• Must complete Odyssey House training and competency requirements before independently administering C-SSRS or completing assigned SMI/SED workflow.

Requirements & Skills

• Demonstrated ability to conduct sensitive, structured interviews and document detailed factual informationaccurately and objectively.
• Working knowledge of substance use, co-occurring behavioral health concerns, MAT/MOUD, withdrawal and overdose risk, recovery systems, homelessness, legal involvement, and social determinants of health.
• Working familiarity with DSM and ASAM terminology sufficient to understand information needed by licensed clinicians without independently diagnosing or determining level of care.
• Strong written communication, organization, record-review, source-reconciliation, and EHR documentation skills.
• Ability to distinguish factual assessment and documentation work from clinical interpretation and licensed decision-making.
• Ability to recognize urgent clinical or safety concerns and follow escalation procedures immediately.
• Ability to work effectively with clients experiencing complex SUD, mental health, medical, trauma, housing, and justice-system needs.
• Ability to support an accountable, solution-oriented, and collaborative culture with Admissions, Clinical Services, medical staff, and program teams.
• Willingness to be trained, effectively integrate, and support Odyssey House Brave Leader and Therapeutic Community principles and tools

Employment offers are contingent upon successful completion of required pre-employment screenings , which may include background checks, fingerprinting, applicable sex offender registry screenings for Adult Residential roles, and other position-related verifications. Roles requiring driving are subject to a Motor Vehicle Record (MVR) review and valid Utah driver’s license.

All employees of Odyssey House are required to adhere to: Odyssey House mission, philosophy, and scope of service; Division of Human Services Code of Conduct and all other relevant service contract requirement standards; ensuring a safe environment for all clients and staff; providing exemplary customer service to both internal and external customers; fostering a positive work environment; ensuring high-quality client care within the scope of the assigned position.

Each employee is expected to clearly understand roles and responsibilities regarding the following: Specific job position, time management, personnel file requirements, client record system, incident reporting, mandatory training requirements, maintaining proper client boundaries, and individual rights of clients and staff.

Physical Demands of the Job: Ability to lift up to 15 lbs., drive (or adequate alternate transportation), sit for prolonged periods, and perform light to moderate physical activity at times.

EEOC Statement: Odyssey House is an equal-opportunity employer. All aspects of employment, including the decision to hire, promote, discipline, or discharge, will be based on merit, competence, performance, and business needs. We do not discriminate based on race, color, religion, marital status, age, national origin, ancestry, physical or mental disability, medical condition, pregnancy, genetic information, gender, sexual orientation, gender identity or expression, veteran status, or any other status protected under federal, state, or local law.