Behavioral Health Clinical Documentation Specialist (BHCDS)
Company: Odyssey House Inc.
Role summary
Behavioral Health Clinical Documentation Specialist (BHCDS) is a role at Odyssey House Inc. in Salt Lake City, Utah, United States (on-site). Posted 2026-09-09. Experience level: 2-5.
- Job title
- Behavioral Health Clinical Documentation Specialist (BHCDS)
- Company
- Odyssey House Inc.
- Location
- Salt Lake City, Utah, United States
- Work arrangement
- on-site
- Category
- Healthcare Support
- Experience level
- 2-5
- Date posted
- 2026-09-09
This is a fantastic opportunity to join a mission-driven organization dedicated to helping individuals and families overcome challenges. You'll play a crucial role in ensuring accurate and timely clinical documentation, supporting patient care and operational efficiency. The role offers a stable career path with room for professional development.
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
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 closel
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