Position description & performance evaluation: privacy officer by compliancedoctor


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									                                                                                                Privacy officer

                                         Facility name
                                 Job description: Privacy officer
Title              Privacy officer
Main function      Responsible for ensuring the facility’s adherence to the Health Insurance Portability and Accountability
                   Act of 1996 (HIPAA) regulations.

Duties and
                   1.   Philosophy
                        a) Supports the facility’s ideology, mission, goals, and objectives
                        b) Performs in accordance with the facility’s policies and procedures
                        c) Follows the facility’s standards for ethical business conduct
                        d) Conducts self as a positive role model and team member
                        e) Recognizes patients’ rights and responsibilities and supports them in performance of job
                        f) Participates in facility committees, meetings, inservices, and activities
                   2.   Communication
                        a) Communicates effectively and professionally with patients, visitors, physicians, and
                        b) Interacts with others in a positive, respectful, and considerate manner
                   3.   Financial practices
                        a) Uses facility resources appropriately and avoids wasteful practices
                        b) Reports wasteful practices
                        c) Analyzes work area and makes recommendations for potential cost-effective improvements
                   4.   Performance-improvement program
                        a) Performs according to established performance-improvement policies and procedures
                        b) Serves as a member of the performance-improvement committee
                        c) Prepares compliance reports and presents opportunities and responsibilities to the
                            performance-improvement committee on a quarterly basis
                   5.   Safety/risk-management program
                        a) Adheres to safety policies and procedures in performing job duties and responsibilities
                        b) Reports observed or suspected safety violations, hazards, and policy/procedure
                            noncompliance to the safety officer or other designated person
                   6    Professional competence
                        a) Participates in continuing education and other learning experiences
                        b) Shares knowledge gained in continuing education with staff
                        c) Maintains membership in relevant professional organizations
                        d) Seeks new learning experiences by accepting challenging opportunities and responsibilities
                        e) Welcomes suggestions and recommendations
                   7.   Duties
                        a) Assists in developing policies and procedures to ensure compliance with HIPAA regulations
                        b) Ensures the facility develops/maintains appropriate privacy, confidentiality, consent, and
                            authorization forms/information notices
                        c) Reviews HIPAA standards, laws, and regulations
                        d) Recommends action to achieve compliance with requirements for the outpatient healthcare
                        e) Provides specific guidance to management, medical staff, and employees
                        f) Coordinates investigation and monitoring of compliance with HIPAA standards and
                        g) Provides initial inservice for new employees promoting understanding of HIPAA issues,
                            laws/regulations, and consequences of noncompliance through written materials and training
                        h) Participates in the development of continuing HIPAA-related education programs for
                        i) Maintains awareness of current changes in HIPAA laws and regulations through personal
                            initiative, seminars, training programs, and peer contact
                        j) Participates in privacy surveillance and incident reporting on a regular basis

                                                                                                    Privacy officer

                          k) Audits employee activity for compliance with all HIPAA regulations within the facility
                          l) Investigates all incidents that involve HIPAA noncompliance and submits necessary reports
                             to the performance-improvement committee and governing body
                          m) Develops a method for continual review and assessment of compliance with HIPAA
                          n) Participates in the development, implementation, and ongoing compliance monitoring of
                             business associate agreements
                          o) Ensures that all privacy/confidentiality requirements and responsibilities are addressed with
                             business associates
                          p) Establishes a mechanism to track access to protected health information and reports on such
                             activity to the performance-improvement committee
                          q) Ensures consistent application of all sanctions for failure to comply with privacy policies and
                             procedures for all employees and business associates
Responsibility for
                     1.   Responsible for assisting in protecting the facility’s financial assets by maintaining compliance
                          with HIPAA regulations
                     2.   Responsible for maintenance/retention of all HIPAA-related documents
                     1.   Cooperative work attitude toward co-employees, management, patients, visitors, and physicians
                     2.   Ability to promote favorable facility image with physicians, patients, insurance companies, and
                          general public
                     3.   Ability to make decisions and solve problems
                     1.   High school diploma or GED certificate
                     2.   Training or courses in business office activities
                     3.   Strong ethical and moral character references

                     1.   Bachelor’s degree, Master’s degree, RN, or equivalent education/experience
                     2.   Experience in medical/legal issues in a healthcare environment
                     3.   Strong medical billing expertise with Medicare/Medicaid/third-party payers
                     4.   Knowledge of HIPAA laws, rules, and regulations
                     5.   Good oral and written communication skills
Job quality
                     1.   Accuracy
                     2.   Attention to detail
                     3.   Timeliness
                     4.   Organization
                     5.   Low degree of supervision needed to accomplish tasks
                     1.   Attendance
                     2.   Punctuality
                     3.   Ability to follow instructions
                     4.   Ability to meet deadlines
                     1.   Ability to sit, stand, and walk for long periods
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