Hospitalist Clinical Documentation Reviewer

OpenTrain AI, Inc.; United States; Hybrid; USD 138,000 - 207,000; Part time

Job summary

OpenTrain AI, Inc. seeks a Hospitalist Clinical Documentation Reviewer to evaluate inpatient records for accuracy, completeness, and clinical alignment with encounters.

You will review H&P, progress notes, and discharge summaries, and provide clear rationales to support consistent decisions. You will adjudicate unclear information, document decisions, and help maintain practical review guidelines and quality standards, drawing on strong documentation audit experience and independent judgment

Qualifications

• MD or DO degree with board certification in Internal Medicine or Family Medicine.
• At least five years as an attending hospitalist or leadership in documentation audit programs.
• Deep familiarity with inpatient documentation standards and hospital quality assurance processes.
• Understanding of how documentation affects coding, billing and compliance.

Responsibilities

• Review inpatient H&P, progress notes and discharge summaries.
• Identify clinically important errors, omissions and inconsistencies.
• Adjudicate ambiguous or conflicting information and document clear decisions.
• Classify documentation issues by severity using structured rubrics.
• Write concise rationales and provide feedback on review standards.

Skills

Documentation review

Clinical judgment

Medical record review

Education

MD or DO with board certification in Internal Medicine or Family Medicine

Job description

The work

As a Hospitalist Clinical Documentation Reviewer, you will evaluate inpatient clinical records for accuracy, completeness, clinical appropriateness, and alignment with the patient encounter. You will use clinical judgment to review H&P, progress notes, and discharge summaries.

You will make consistent decisions on unclear or conflicting documentation, explain your reasoning, and help maintain practical review guidelines and quality standards.

• Review inpatient H&P, progress notes, and discharge summaries.
• Identify clinically important errors, omissions, and inconsistencies.
• Adjudicate ambiguous or conflicting information and document clear decisions.
• Classify documentation issues by severity using structured rubrics.
• Write concise rationales and provide feedback on review standards.

What it pays and takes

This is a remote, part-time contractor role for experienced hospitalists or clinicians with strong documentation review experience. The work requires independent judgment and clear written and verbal communication about complex clinical decisions.

• Pay: $100 to $150 per hour.
• Time: 20+ hours per week.
• Location: Remote, in the countries supported for this role.
• Language: English.
• Required: MD or DO degree with board certification in Internal Medicine or Family Medicine.
• Required: At least five years as an attending hospitalist or demonstrated leadership in documentation audit programs.
• Required: Deep familiarity with inpatient documentation standards and hospital quality assurance processes.
• Required: Understanding of how documentation affects coding, billing, and compliance.
• Helpful: Experience with clinical documentation improvement, documentation QA, audits, or clinical quality leadership.

About AI training work

AI training work uses human review to help improve artificial intelligence systems. In this role, your clinical judgments and explanations help assess the quality and reliability of AI-related documentation work, while your medical expertise supports accurate evaluation of complex records.