In this role, you'll evaluate inpatient clinical documentation (H&Ps, progress notes, discharge summaries) for clinical accuracy, completeness, and fidelity to the patient encounter. You'll adjudicate discrepancies, flag clinically significant errors or omissions, and apply consistent quality standards across reviews. This is a unique opportunity for experienced hospitalists who care deeply about clinical excellence and enjoy articulating nuanced clinical reasoning and judgment in both written and verbal formats.
Responsibilities
Review inpatient clinical documentation and assess accuracy, completeness, and clinical appropriateness.
Adjudicate ambiguous or conflicting information and render clear, well-reasoned judgments.
Identify clinically significant errors, omissions, or inconsistencies and categorize them by severity.
Apply structured rubrics and quality criteria consistently across cases.
Provide concise written rationale supporting each adjudication decision.
Contribute to refining review guidelines and quality standards.
Preferred skills
MD or DO, board-certified in Internal Medicine or Family Medicine.
Deep familiarity with inpatient documentation standards and hospital QA processes.
Familiarity with how documentation impacts coding, billing, and compliance.
Comfortable working independently in a remote environment.
Experience and education
5+ years as an attending hospitalist, or demonstrated leadership of documentation audit programs.
Experience with clinical documentation improvement (CDI) programs is a plus.
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