Remote 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

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