Inpatient Clinical Documentation Reviewer

About the role

Gramian Consultancy, a boutique consultancy focused on IT professional services and engineering talent solutions, is seeking experienced physicians to review inpatient clinical documentation. The reviewer assesses the clinical accuracy, completeness and consistency of documentation, adjudicates conflicting information, identifies clinically significant errors and provides clear, evidence-based reasoning for each decision. The role suits physicians with strong hospital medicine experience and a commitment to clinical quality.

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 improving documentation review guidelines and quality standards.

Required profile

• 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.
• Ability to work independently and maintain consistent quality in a remote environment.