Inpatient Clinical Documentation Reviewer

Gramian Consultancy, a boutique firm specializing in IT professional services and engineering talent solutions, is seeking experienced physicians to join our team. We focus on connecting companies with professionals who align well with their needs, leveraging our strong background in software engineering and leadership. This role involves reviewing inpatient clinical documentation to ensure its clinical accuracy, completeness, and consistency. The ideal candidate will evaluate histories and physicals, progress notes, and discharge summaries, resolve conflicting information, identify clinically significant errors, and provide clear, evidence-based explanations for their decisions. This position is well-suited for physicians with substantial hospital medicine experience and a dedication to maintaining high clinical quality and documentation standards.

Key Responsibilities

- 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.

Required Qualifications

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

This opportunity offers physicians the chance to apply their clinical expertise in a critical quality assurance role, supporting healthcare organizations in maintaining high standards of patient care documentation. Gramian Consultancy values professionals who are committed to clinical excellence and continuous improvement in healthcare documentation practices.