Inpatient Clinical Documentation Reviewer

Job Description:

• Review inpatient clinical documentation, including histories and physicals (H&Ps), progress notes, and discharge summaries.
• Assess documentation for clinical accuracy, completeness, and alignment with the patient encounter.
• Adjudicate ambiguous, conflicting, or inconsistent clinical information using sound medical judgment.
• Identify and categorize clinically significant errors, omissions, and discrepancies by severity.
• Apply structured review rubrics and quality criteria consistently across cases.
• Provide concise, well-reasoned written explanations supporting review decisions.
• Contribute to the improvement of documentation review guidelines and quality standards.

Requirements:

• MD or DO degree.
• Board certification in Internal Medicine or Family Medicine.
• At least 5 years of experience as an attending hospitalist, or demonstrated leadership of clinical documentation audit programs.
• Strong knowledge of inpatient documentation standards and hospital quality assurance processes.
• Excellent clinical reasoning and the ability to assess complex or ambiguous documentation.
• Strong written and verbal communication skills, including the ability to explain clinical judgments clearly.
• Ability to work independently and maintain consistent quality in a remote environment.