Inpatient Clinical Documentation Reviewer

This is a fully remote position, open to applicants in Brazil, +5 more countries.

📋 Description

• Evaluate inpatient clinical documentation, which includes histories and physicals (H&Ps), progress notes, and discharge summaries.

• Analyze documentation for clinical precision, completeness, and correspondence with the patient encounter.

• Resolve ambiguous, conflicting, or inconsistent clinical information using sound medical judgment.

• Detect and classify clinically significant errors, omissions, and discrepancies based on their severity.

• Consistently apply structured review rubrics and quality criteria across various cases.

• Provide clear, well-reasoned written justifications that support review decisions.

• Assist in enhancing documentation review guidelines and quality standards.

⛳️ Requirements

• MD or DO degree.

• Board certification in Internal Medicine or Family Medicine.

• A minimum of 5 years of experience as an attending hospitalist, or proven leadership in clinical documentation audit programs.

• Strong understanding of inpatient documentation standards and hospital quality assurance processes.

• Excellent clinical reasoning skills and the capability to evaluate complex or ambiguous documentation.

• Strong written and verbal communication abilities, including the capacity to articulate clinical judgments clearly.

• Capability to work independently while maintaining consistent quality in a remote setting.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and continuing education.

• Supportive work environment with a focus on quality patient care.