Director of Quality, Compliance and Privacy

Revision Date: 5/9/2022
Department: Executive
Employment Status: Full-Time
Program: Quality/Compliance/Privacy
FLSA Status: Exempt
Reports To: Executive Director of Tribal Administration
Schedule: Exempt
Supervises: Assistant Director of Quality Assurance/Data Analytics, Risk Management Manager, Accreditation and Policy Manager, Compliance and Privacy Manager, HSE Advisor, Infection Control and Employee Health Specialist
Preference: TERO Ordinance 2017-01, P.L. 93-638

Job Summary

This position has principal authority and responsibility for the development of compliance implementation, HIPAA and 42 CFR Part 2 Privacy rule oversight and the quality management program for the Tribe.

Essential Functions

Quality Management Responsibilities:

• Supports all managers and senior leaders in the development, coordination, and implementation of the Tribe's quality program
• Works closely with the Quality Committee and Health Board to develop and maintain a system for the monitoring and evaluation of quality improvement plans for effectiveness and sustainability
• Keeps leadership aware of risks and opportunities for improvement that require system modifications and leadership support
• Facilitates the organization's participation in outside quality-related initiatives that serve to advance quality.
• Assists in establishing and managing quality management policies and procedures in cooperation with clinical staff and Tribal Leadership
• Works collaboratively with and across all the quality specialties (safety, human resource management, orientation, continuing education, corporate compliance, utilization management, clinical case management, HIPAA compliance, pharmacy and therapeutics, contract management, credentialing, privileging, peer review, un'ina advocacy, service recovery, un'ina satisfaction, employee health, and personal performance and growth) to minimize the functional silo approach to quality and create an effective safety net that maximizes the potential to get work right the first time while minimizing the risk for error and avoiding the wasteful utilization of resources
• Integrates quality and risk prevention/management related activities to facilitate the timely and effective implementation of quality improvement opportunities when risks that can threaten an un'ina, employee or the organization are identified
• Partners with healthcare team members, un'ina and families to continuously solicit feedback and information to improve un'ina safety and quality in ways that foster strong un'ina satisfaction. Receives and investigates un'ina complaints with the goal of timely resolution for the un'ina in an un'ina-focused way
• Acts as a coach and mentor to all levels of staff, providing feedback and support in areas of compliance and performance improvement
• Complies and maintains various codes, laws, rules, and regulations concerning un'ina care, including those mandated by state and federal agencies. Working with the quality specialties to ensure an effective system for knowing the most current outside standards that can impact care delivery and clinic operations
• Prepares reports for leadership, management and the Council regarding trends, patterns, opportunities for improvement and pertinent quality-related activities
• Facilitates the development and implementation of quality-related training for orientation and continuing education
• Serves as the System Administrator for the usage of Quality support system of the Tribe's quality, risk prevention, un'ina satisfaction and employee satisfaction activities

Compliance and Privacy Officer Responsibilities:

• Acts as the HIPAA and 42 CFR Part 2 Privacy Officer
• Investigate all instances of suspected illegal or unethical conduct, and seek the advice of qualified legal counsel as needed
• Oversee the development and plan for a Kenaitze Indian Tribe's overall and Health System Compliance Program
• Establishment of a Compliance Committee
• Directing methods to improve the Tribe's efficiency and quality of services and to reduce the Tribe's vulnerability to fraud and abuse, Privacy such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing, maintaining, implementing, and disseminating written practice standards and procedures
• Periodically revising the Compliance Program, Privacy rule or recommending such revisions, in light of changes in the needs of the Tribe or changes in the law and/or in the standards and procedures of government and private payer health plans
• Developing, coordinating, and participating in training programs that focus on the components of the Compliance Program, HIPAA Privacy and seek to ensure that all as well as employees, contractors, agents, consultants, volunteers, and others who act on the Tribe's behalf are knowledgeable of, and comply with, pertinent Federal and State standards and the requirements of the Tribe's Compliance Program
• Investigating, independently or with qualified legal counsel, and acting on any report or allegation of unethical or improper conduct or business practices, and implementing and monitoring appropriate corrective action and/or subsequent compliance
• Prepares and delivers presentations to leadership and teams about the Program, and develops, delivers and tracks special training for Dena'ina Wellness Center
• Develops reviews, completes assessments, and manages Compliance Action Plan (CAP) development and remediation for the Tribe
• Track and ensure compliance with privacy requirements for disclosures of protected health information, including business associate agreements, and requests for medical records and subpoenas
• Monitor industry and regulatory developments, and make compliance and privacy recommendations
• Follow federal, state and local legal guidelines

It is the intent of this job description to highlight the essential functions of the position; however, it is not an all-inclusive list. The incumbent may be called upon and required to follow or perform other duties and tasks requested by his/her supervisor, consistent with the purpose of the position, department and/or the Kenaitze Indian Tribe's objectives.

Performance Outcomes

In performance of the above essential functions, the Director of Quality/Compliance/Privacy shall meet the following performance outcomes:

• Current, accurate and timely financial information is communicated with staff, leadership, Council, tribal departments, community partners, grantors, and auditors
• The Quality/Compliance/Privacy team is high performing, fostered by a positive work environment and centered on learning and appreciation for each team members' strengths
• Goals and outcomes of the annual strategic plan are successfully completed in a timely manner
• Solutions are provided, based on accurate information and data, when problems arise
• Policies and procedures are reviewed annually and new policies and procedures are created as needed

Working Conditions

Lifting Requirements

• Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Physical Requirements

• Stand or Sit (Stationary position)
• Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)
• Stoop, kneel, crouch or crawl (Position self (to), Move)
• Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)
• See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)
• Pushing or Pulling
• Repetitive Motion

OSHA Categories

• Category III - Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid

Equipment and Tools

• Computer
• Copier
• Fax
• Scanner
• Other Office Equipment

Travel

• Local
• In-State
• Out-of-State

Qualifications

Education

• Bachelor's degree in law, health sciences, or related field or a combination of education and experience may be substituted for a degree

Experience

• Minimum seven (7) years of experience in health care compliance
• Previous Healthcare Privacy Officer experience preferred
• Knowledge of principals of effective risk management
• Knowledge of available resources within the Alaska Tribal Health System and community

Preferred

• Master's degree in law, health sciences, or related field
• Paralegal certificate
• Healthcare Corporate Compliance and Privacy certification
• Certified Professional in Health Care Quality (CPHCQ) or similar certification
• Knowledge and experience working with cultural diversities

License/Certification

• Must have a valid Alaska State driver's license and must remain insurable under the Tribe's policy, or obtain within 90 days of hire
• Must be a Public Notary or obtain within 90 days of hire

Special Skills

• Ability to effectively communicate, verbally and in writing, with all levels of staff
• Ability to maintain strict confidentiality with medical information, as well as other confidential information and conform to HIPAA and 42 CFR Part 2 regulations
• Ability to work both independently and as a team, with frequent interruptions, occasional public contact, and occasional crisis situations
• Must have strong understanding of fiscal, administrative and clinical systems
• Healthcare industry knowledge in all aspects of compliance, privacy and quality management
• Strong confident, leader and motivator with a track record of being a self-starter who exercises sound judgment and impeccable integrity
• Highly organized and focused on delivering results with experience in analysis and reporting
• Proficiency with Microsoft Suite, or obtain training within 90 days of hire
• Conducts business in a service-oriented manner that is attentive, pleasant, respectful and kind when dealing with un'ina, visitors, co-workers and others
• Ability to work independently as well as collaboratively