Behavioral Health Clinical Documentation Specialist (BHCDS)

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

Full-Time Benefits Include:

• $9,000/year tuition eligibility
• Paid continuing education/training opportunities
• Monthly incentives and awards
• Casual dress and atmosphere
• Health insurance: medical, dental, vision, FSA, long & short-term disability
• Competitive 403b match after 1 year 
• Accrue up to 34 paid days off annually 
• Wellness perk: convert ½ of unused sick time to vacation at year-end
• Sabbatical program after 5 years of service (we pay you to take a vacation!)
• On-demand pay – access earned wages early (conditions apply)
• Extra time off & gift packages for employees after 90 days

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

Case Manager

Salt Lake City, UT

Description

Odyssey House is looking for a Full-Time Case Manager for our Outpatient Facility in Sugarhouse!

Summary: You can make a difference in people’s lives and our community! Odyssey House, a 501(c)3 non-profit, is recognized as the best mental health and addiction treatment center in Utah. If you want to expand your experience in the social work and addiction field, we can help! We provide you with opportunities to learn and start a career with flexible schedules to accommodate school and family life. This role is critical to the client and the organization. Odyssey is a large and growing agency, and we are BIG on promoting from within. It is common for people who start here to get promoted to full-time or leadership roles. So come work with the people in our care; it is deeply rewarding!

Job Location: Salt Lake City

Compensation: $39,520 salary

Full-Time Benefits Include:

• $9,000/year tuition eligibility
• Paid continuing education/training opportunities
• Monthly incentives and awards
• Casual dress and atmosphere
• Health insurance: medical, dental, vision, FSA, long & short-term disability
• Competitive 403b match after 1 year 
• Accrue up to 34 paid days off annually 
• Wellness perk: convert ½ of unused sick time to vacation at year-end
• Sabbatical program after 5 years of service (we pay you to take a vacation!)
• On-demand pay – access earned wages early (conditions apply)
• Extra time off & gift packages for employees after 90 days
• 24/7 Employee Assistance Program (EAP) for mental health and more  

Core Responsibilities: As a member of our team, you will be trained in the skills required to effectively assess clients' needs, connect them with appropriate resources, accurately document services, maintain healthy boundaries, and ensure client safety. You will work closely with our clinical staff, coordinating care and providing direct support to our clients. Additionally, you will have the opportunity to accompany clients on recreational outings.

Day in the Life: You will build meaningful relationships with clients, providing them with individualized attention and support to facilitate positive life changes. This will involve connecting clients with essential resources, communicating with their support systems, and developing therapeutic interventions to help them achieve their goals. You will also hold clients accountable for their progress and provide positive reinforcement for their successes. Overall, you will play a vital role in ensuring the long-term success of our clients. 

Job Description

• Interview and assess client needs and resources on case management caseload.
• Coordinate with licensed therapists in developing treatment plans and goals consistent with client needs.
• Monitor outcome and client compliance.
• Maintain client records to ensure all paperwork is completed as required.
• Verify funding eligibility for Medicaid and manage Medicaid status during treatment episodes.
• Submit reports to supervisor, as requested.
• Assist in arranging client appointments/paperwork with community resources, follow up to ensure client progress, and chart all relevant activities.
• Complete service documentation within the appropriate client management system within 24 hours.
• Accurately document services using ASAM (American Society of Addiction Medicine) Dimensional Analysis format, including all required elements.
• Proactively involve and communicate with collateral supports, including family, significant others, probation officers, judges, caseworkers, and others.
• Document all incidents immediately and report as required.
• Complete accurate and thorough client reports in required timeframes, such as court reports.
• Other duties as assigned. 

Requirements

Licensure / Education / Prior Experience Required:

Bachelor's degree in a related field, two years of related employment, and/or program graduate recommended by staff for employment in pursuit of licensure preferred.

• Willingness and ability to pass a criminal background check
• First Aid and CPR Certification (available at Odyssey House)
• Must comply with annual TB tests, Flu, and other immunizations as required
• Must meet employment eligibility
• Must be able to work variable shifts as needed

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.