We are sharing a specialised consulting opportunity for experienced hospitalists with deep expertise in inpatient medicine, clinical documentation, clinical adjudication, and quality review to evaluate inpatient records for accuracy, completeness, and fidelity to the underlying patient encounter.
Selected professionals will review H&Ps, progress notes, and discharge summaries; adjudicate conflicting or ambiguous clinical information; identify significant documentation errors or omissions; and apply structured quality standards across cases. This opportunity is particularly suited to physicians who combine strong inpatient clinical judgement with precise written reasoning.
Key Responsibilities
Inpatient Documentation Review
- Review histories and physicals, progress notes, and discharge summaries
- Assess documentation for clinical accuracy and completeness
- Evaluate whether records appropriately reflect the patient encounter
- Identify missing or inadequately documented clinical information
- Apply hospitalist-level judgement to complex inpatient cases
Clinical Adjudication & Reasoning
- Adjudicate ambiguous or conflicting clinical information
- Render clear and defensible clinical decisions
- Distinguish meaningful discrepancies from minor documentation variation
- Apply consistent judgement across comparable cases
- Provide concise rationale supporting each adjudication decision
Error Detection & Severity Assessment
- Identify clinically significant errors and omissions
- Detect inconsistencies across inpatient documentation
- Categorise findings according to severity and clinical importance
- Evaluate whether discrepancies may affect interpretation of the case
- Escalate material documentation concerns through defined review processes
Quality Standards & Rubric Application
- Apply structured review rubrics consistently across cases
- Evaluate documentation against established quality criteria
- Maintain consistency across repeated adjudication workflows
- Identify unclear or insufficient review criteria when encountered
- Support reliable and repeatable clinical-quality evaluation
Guideline Development & Quality Improvement
- Contribute to refinement of clinical review guidelines
- Provide feedback on documentation-quality standards
- Identify recurring patterns in documentation weaknesses
- Support continuous improvement of review methodology
- Communicate clinical reasoning clearly in written and verbal formats
Ideal Profile
- MD or DO degree
- Board certification in Internal Medicine or Family Medicine
- 5+ years of experience as an attending hospitalist, or comparable leadership of clinical documentation audit programmes
- Deep familiarity with inpatient medicine and hospital documentation standards
- Strong experience reviewing complex inpatient clinical records
- Excellent clinical judgement and adjudication capabilities
- Ability to identify clinically meaningful errors, omissions, and inconsistencies
- Familiarity with hospital quality-assurance processes
- Experience with Clinical Documentation Improvement programmes is advantageous
- Understanding of how documentation affects coding, billing, and compliance
- Strong written communication skills
- Ability to explain nuanced clinical reasoning concisely
- High attention to detail and consistency
- Comfortable applying structured rubrics across repeated case reviews
- Able to work independently in a remote professional environment
Engagement Details
- Independent contractor engagement
- Fully remote
- Compensation: $100–$150/hour
- Work will involve inpatient documentation review, clinical adjudication, error detection, rubric-based evaluation, and quality-standard refinement
- Materials may include H&Ps, progress notes, discharge summaries, and related inpatient documentation
- Strong hospitalist experience and clinical documentation expertise are central to this engagement
- Contributors will be expected to provide concise written rationale for adjudication decisions
- Familiarity with CDI, hospital QA, coding, billing, and compliance workflows is valuable
- Project scope, case mix, and review criteria may evolve depending on project requirements
- Work must be completed without using confidential, proprietary, patient-identifiable, protected health, or unpublished clinical information belonging to any employer, healthcare organisation, patient, client, or other third party
About the Platform
This opportunity is available through 24-MAG LLC. We connect experienced professionals with remote consulting opportunities across technical, evaluation, and project-based workstreams.
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