Quality Assurance HIPAA Compliance Officer

JOB SUMMARY: Quality Assurance/HIPPA Compliance Officer is responsible for ensuring the Nooksack Health Department operates in full compliance with Tribal, Federal, and State laws and regulations, including strict adherence to the Health Insurance Portability and Accountability Act (HIPAA). This position plays a key role in promoting a culture of privacy, patient safety, and highquality care. Primary responsibilities include overseeing quality assurance initiatives, conducting regular audits of medical records and patient services, monitoring environmental and clinical safety standards, and ensuring all staff are appropriately trained in HIPAA regulations and quality care practices. This role requires close collaboration with clinical and administrative staff to implement and maintain effective quality improvement strategies, while safeguarding the confidentiality, integrity, and availability of protected health information (PHI) in accordance with HIPAA and Tribal privacy policies.

MAJOR TASKS AND RESPONSIBILITIES:

A broad range of quality assurance activities involving but not limited to:

1. Work toward achieving Accreditation Association for Ambulatory Health Care (AAAHC) status—a mark of excellence that reflects adoption of best practices and compliance with nationally recognized standards of care.

2. Coordinate and assist with staff training, including health professional in-service training and new staff orientation, to improve the knowledge and skills of Health Department staff in fulfilling their duties.

3. Coordinate Health Clinic staff meetings and assist with health promotion activities.

4. Develop, in conjunction with program managers, quality improvement program policies, procedures, and strategies to establish performance benchmarks, corrective action plans, and ongoing progress monitoring.

5. Conduct routine audits of patient services and program operations, and monitor environmental and patient safety standards.

6. Conduct quarterly Electronic Health Record (EHR) audits in partnership with the EHR Specialist to ensure compliance with healthcare service requirements. Provide regular updates to the Health Director and Medical Clinic Manager regarding audit findings or compliance issues.

7. Assist, as needed, with audits requested by government or private agencies. Nooksack Indian Tribe Job Description

8. Ensure patient service registries and data entry are accurate, current, and compliant with Indian Health Service and other contract/grantor eligibility and billing standards.

9. Monitor the compilation of demographic and service data—such as RPMS, Diabetes Registry, PRC, medical records, WIC, and vendor data—provided by the EHR Specialist and/or Certified Application Counselor (CAC) to ensure compliance with requires measures.

10. Collaborate with the EHR Specialist, CAC, and healthcare providers to support Government Performance and Results Act (GPRA) reporting and integration of national clinical guidelines into routine practices.

11. Work with the Purchased and Referred Care (PRC) program to ensure full compliance with Indian Health Service standards.

12. Closely monitor maintenance schedules for medical and safety equipment to ensure proper function, scheduling annual inspections, and verifying documentation of all routine inspections.

13. Maintain a current Master Binder of Safety Data Sheets (SDS) and ensure each department has updated SDSs for housekeeping, medical, and dental products.

14. Coordinate with the Maintenance Department, Facilities and Safety Coordinator, and external vendors/contractors to ensure health clinic facility maintenance, repairs, and upgrades meet safety and regulatory standards.

15. Serve as the Health Department's designated HIPAA Privacy Officer, responsible for receiving, documenting, and investigating HIPAA-related complaints and potential breaches of protected health information (PHI).

16. Conduct thorough investigations of potential HIPAA violations or unauthorized disclosures, coordinate mitigation efforts, and ensure timely breach reporting in accordance with federal and Tribal requirements.

17. Develop and implement policies and procedures to ensure HIPAA compliance across all departments, including privacy and security of PHI in electronic, paper, and oral forms.

18. Collaborate with IT, clinical, and administrative staff to monitor HIPAA compliance safeguards and to support a culture of patient confidentiality, security awareness, and regulatory accountability.

19. Lead efforts to protect patient safety and the confidentiality, integrity, and security of health information by proactively identifying risks, addressing potential vulnerabilities in clinic operations, and ensuring that all safety protocols, privacy safeguards, and incident response procedures are actively maintained and enforced.

20. Make sure licensed medical staff are in compliance with their licensure requirements needed to perform they job duties.

OTHER DUTIES:

Because of the Tribe's commitment to community service and the well-being of its members, each employee may be expected to perform a wide range of office and field duties from time to time. Such duties may or may not be related to their regular responsibilities.

PREFERENCE: 

Indian Preference Policy applies to this and all positions with the Nooksack Indian Tribe.

MINIMUM QUALIFICATIONS

The following qualifications are required for the applicant to have, in order to be considered for the position.

REQUIRED EDUCATION, EXPERIENCE AND TRAINING FOR POSITION:

• Must possess, at a minimum, a Bachelor’s Degree, 

or…

• A minimum of five (5) year of work experience demonstrating advance knowledge and application of Healthcare Quality Assurance and compliance with government regulatory standards, financial management, and super user level knowledge of computerized patient data management and accounting systems.

• A minimum of 2 years of program management, program implementation, and/or program review.

PREFERED EDUCATION, EXPERIENCE AND TRAINING:

• Working knowledge of HIPAA, AAAHC standards, and other applicable healthcare guidelines, policies, and regulatory procedures. Familiarity with health care compliance requirements at the Tribal, State, and Federal levels preferred. Professional certification in healthcare quality or compliance (such as CHC or CPHQ) is highly desirable. Experience in Tribal or public health systems is a plus.

REQUIRED SKILLS/KNOWLEDGE/ABILITIES POSITION:

• Must demonstrate integrity, honesty, and uphold high ethical standards in all professional activities.

• Excellent verbal and written communication skills.

• Knowledge of Native American Indian culture and unique healthcare needs of the population.

• Knowledge of healthcare Quality Assurance procedures and application.

• Strong business skill.

• Excellent problem-solving skills, including the problems inherent to a health clinic setting.

• Advanced skills in a computer database management, electronic data storage systems, electronic health records systems, patient management systems, and statistical analysis software programs.

• Advanced skills in data collection, data management, and quality control.

• Knowledge or willingness to learn the basic principles, practices, and standards of care for a variety of healthcare services.

• Must be knowledgeable of the Federal Privacy Act and HIPAA laws, maintaining full compliance with all related federal regulations.

• Must be dependable and able to work independently with little supervision.

• Must attend and intermittently facilitate staff meetings and conduct QA staff training, as needed and/or required.

• Requires daily communication with supervisor and health program managers.

• Must work positively and constructively with peers, co-workers, supervisors, and always conduct self respectfully and courteously with patients and clients.

• Shall embrace cultural differences and interact positively with internal staff as well as external contacts in a culturally competent and respectful manner.

• Must maintain good moral character standing throughout employment with the Nooksack Indian Tribe.

• Must be willing to travel to meetings, trainings and other Nooksack Tribal offices as directed.

REQUIRED CONDITIONS OF EMPLOYMENT:

 Must pass alcohol/drug test at time of hire and throughout employment.

 Must pass criminal background check at time of hire and periodically thereafter.

REQUIRED LICENSES OR CERTIFICATIONS:

• Must have and maintain throughout employment a valid Washington State Driver’s License and meet the insurability requirements of the Tribe. (Must Provide Driving Abstract at time of hire).

PHYSICAL REQUIREMENTS (The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.):

• Ability to work at a computer terminal for extended periods of time on a daily basis.

• Physical requirements for this position; hearing, seeing, speaking, feeling, reaching and repetitive motions.

• This position requires sitting for long periods of time.

• This position requires exerting up to 40 pounds of force in order to lift, carry, pull or remove objects.

I have read and understand the position requirements as stated above I further, understand that occasionally I may be instructed to perform duties that are not listed above but are relative to my position.

Heal