Inpatient Clinical Documentation Reviewer

About Gramian

Gramian Consultancy is a boutique consultancy specializing in IT professional services and engineering talent solutions. With a strong background in software engineering and leadership, we help companies build high-performing teams by matching them with professionals who truly fit their needs.

About the Role

We are seeking experienced physicians to review inpatient clinical documentation and assess its clinical accuracy, completeness, and consistency. You will evaluate histories and physicals, progress notes, and discharge summaries, adjudicate conflicting information, identify clinically significant errors, and provide clear, evidence-based reasoning for your decisions. This role is suited to physicians with strong hospital medicine experience and a commitment to 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.

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.