Remote Senior Inpatient Clinical Documentation Reviewer

Gramian Consulting Group; México; Remote; MXN 1,100,000 - 1,500,000; Full time

Job summary

Gramian Consultancy seeks experienced physicians to review inpatient clinical documentation for accuracy, completeness, and consistency. You will evaluate histories and physicals, progress notes, and discharge summaries, adjudicate conflicting information, and provide 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, with the ability to work independently in a

Qualifications

• MD or DO degree required and board-certified in Internal Medicine or Family Medicine.
• Minimum 5 years as an attending hospitalist or leadership in clinical documentation audits.
• Strong knowledge of inpatient documentation standards and QA processes.
• Excellent clinical reasoning with ability to interpret complex or ambiguous documentation.
• Clear written and verbal communication to explain clinical judgments.

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.

Skills

Clinical reasoning

Written communication

Verbal communication

Independent work

Education

MD or DO degree

Board certification in Internal Medicine

Board certification in Family Medicine

Job description

Gramian Consultancy seeks experienced physicians to review inpatient clinical documentation for accuracy, completeness, and consistency. You will evaluate histories and physicals, progress notes, and discharge summaries, adjudicate conflicting information, and provide 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, with the ability to work independently in a