POSITION: CHIEF QUALITY OFFICER
RESPONSIBLE TO: DEPUTY CHIEF EXECUTIVE OFFICER
SALARY: Step Range: 37 ($87,713) – 56 ($153,806); Full Benefits
CLASSIFICATION: Professional/Management, Regular, Full-Time
LOCATION: Klamath Tribal Health & Family Services
3949 South 6th Street
Klamath Falls, Oregon
BACKGROUND: P.L. 101-630 Level
POSITION OBJECTIVES
The Chief Quality Officer has principal authority and responsibility for the development, implementation, oversight, and evaluation of all aspects of the Klamath Tribal Health & Family Services’ (KTHFS) Compliance Program. The Chief Quality Officer is responsible for ensuring compliance with all applicable laws, regulations, and organization policies. In fulfilling this duty, the Compliance Officer shall have direct access to the Governing Board and legal counsel to report compliance activities, risks, and corrective actions independently of operational leadership.
The Chief Quality Officer will report directly to the Deputy CEO, who will oversee the individual’s performance as the Chief Quality Officer. Responsibilities may include meeting certain professional goals and objectives; supervising and mentoring subordinates; demonstrating and encouraging leadership; and/or maintaining good judgment and discretion in carrying out the duties of the Chief Quality Officer.
The Chief Quality Officer will perform a wide variety of complex administrative functions in support of Klamath Tribal Health & Family Services. The Chief Quality Officer will serve as the HIPAA Privacy Officer on behalf of KTHFS and the Klamath Tribes, a hybrid entity.
MAJOR DUTIES AND RESPONSIBILITIES
1. Provide direct supervision of the Quality Assurance Specialist.
2. Oversee and monitor the development and implementation of KTHFS Compliance Program and Quality Assurance/Quality Improvement Plan and policies.
3. Direct methods to improve KTHFS efficiency and quality of services and to reduce KTHFS vulnerability to fraud and abuse, such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing, maintaining, implementing, and disseminating written practice standards and procedures. Coordinates and facilitates the monitoring program including but not limited to mock surveys, external agency audits, and tracer activities to identify areas for improvement. Coordinate the development an review of policies and plans for compliance with the appropriate leaders and their respective departments.
4. Develop, coordinate, and participate in training programs that focus on the components of the Compliance Program and seek to ensure that all Health Center Governing Body members, as well as employees, contractors, agents, consultants, volunteers, and others who act on KTHFS’ behalf (Staff) are knowledgeable of, and comply with, pertinent Federal and State standards and the requirements of KTHFS’ Compliance Program.
5. Responsible for HIPAA and Privacy Training at new hire orientation and regular intervals as needed throughout the year.
6. Coordinate with the Human Resource Department to ensure that employees and contract licensed independent practitioners have been queried/screened against the U.S. Department of Health and Human Services, Office of Inspector General’s List of Excluded Individuals and Entities on a regular basis (e.g., at the time of hire, monthly, annually).
7. Investigate, independently or with qualified legal counsel, and act on any report or allegation of unethical or improper conduct or business practices, and implement and monitor appropriate corrective action and/or subsequent compliance.
8. Direct the development and implementation of corrective actions in response to reports or findings of potential non-compliance, including conferring with the Human Resource Director and/or the Deputy CEO regarding the enforcement of disciplinary action.
9. Maintain compliance by auditing programs and tracking laws and regulations that may affect the organization’s policies and procedures. Perform internal compliance audits and monitoring of programs in order to detect any indication of noncompliance with requirements and compliance policies.
10. Maintain all required logs and requests including but not limited to Disclosure Logs HIPAA Complaint Log, Patient Complaint Log, Incident Report Log and Compliance Concern Log. Retain documentation of all audits, inspections, licenses, and re-certifications ().
11. Coordinate with IST Director on completion and retention of Business Associate Agreements and HIPAA Security Investigations.
12. Risk Management responsibilities to include shared responsibility and oversight of Adverse Incident and Near Miss Events.
13. Collaborate with various departments to prepare for external audits.
14. Monitors new regulatory standards and other applicable federal laws, develops and implements action plans for compliance and serves as a resource for regulatory standard interpretation.. Responsible for applying for accreditation, preparing for site visits and working with KTHFS departments on any corrective action needed.
15. Report information on the activities of the Compliance Program to the Deputy CEO and to the Compliance-related committees on a quarterly basis.
16. Compliance Program Tasks:
- Draft compliance and other policies
- Communication of compliance standards
- Repository of compliance information
- Coordinating and monitoring audits
- Oversight of quarterly Compliance-related Committee meetings
- Conduct investigations of alleged misconduct
- Ensure proper documentation of compliance activities
- Provide education and training on regulatory requirements, compliance program, etc. upon initial hire date and annually thereafter. Annual review and revision (as needed) of the Compliance Program
- Oversee and monitor the Compliance Program
17. Prepare for and/or conduct compliance site visits to provider locations; review with appropriate staff the compliance audit work plans to ensure implementation of plans and improvement of services.
18. Responsible for review and analysis of assigned compliance requirements and grant programs; process implementation reports and annual reports of findings and future needs.
19. Serve as a working member of Klamath Tribal Health & Family Services’ quality improvement committee and other committees as assigned; attend other department and committee meetings to ensure the organization’s overall Quality Improvement plan is implemented and in compliance with applicable regulations.
20. Serve as the HIPAA Privacy Officer for KTHFS and the Klamath Tribes (a hybrid entity); point of contact for HIPAA Privacy complaints/violations. Serve as the principle investigator on charges of breached confidentiality involving protected health information. Report findings to the Deputy CEO.
21. Ensure organizational compliance with federal regulations, to include compliance with 42 CFR Part 2 Rules governing the confidentiality of substance use disorder patient records; including providing initial training for new hires and on-going education for staff members.
22. Work closely with HIPAA Security Officer on HIPAA Security Rule implementation and documentation of Security Rule requirements.
23. Perform a wide variety of administrative functions to meet Klamath Tribal Health & Family Services’ responsibilities.
24. Provide a monthly activity report and annual report to the Deputy CEO including but not limited to trending data related to incidents reported and trainings completed.
25. Like all employees of the Klamath Tribes, the incumbent will be called upon to accomplish other tasks that may not be directly related to this position, but are integral to the Klamath Tribes’ broader functions, including but not limited to, assisting during Tribal sponsored cultural, traditional, or community events that enable the successful operation of programs and practices of The Klamath Tribes as aligned with The Klamath Tribes’ Mission Statement. Some of these tasks may be scheduled outside of regular work hours, if necessary.
SUPERVISORY CONTROLS
The Chief Quality Officer works under the supervision of the Deputy CEO. This position works independently, resolving normal conflicts according to established procedures and experience. Unusual, new, or complex assignments which require deviation from experience or precedents are discussed with the Deputy CEO; however, the employee exercises initiative in researching answers and solving problems.
KNOWLEDGE, SKILLS, ABILITIES
Experience with medical records and associated requirements, including disclosure of information regulations.
Knowledge of HIPAA rules compliance, 42 CFR Part 2 Rules governing the confidentiality of substance use disorder patient records, the Privacy Act, Freedom of Information Act and other Federal and State requirements.
Knowledge of and ability to interpret standards of accreditation, including, but not limited to Accreditation Association for Ambulatory Healthcare (AAAHC)
Knowledge and understanding on importance of confidentiality. Ability to maintain strict confidentiality.
Strong interpersonal and communication skills; demonstrating initiative, decisiveness, ability to work effectively with and motivate others, strong professional judgment under pressure, and ability to successfully manage a diverse and demanding workload.
Strong planning, organizing, and time management skills
Demonstrated ability to work effectively and congenially with employees at diverse levels.
Ability to cope with conflicting points of view, function under pressure and demonstrate discretion, integrity and fair mindedness.
Strong commitment to actively supporting an ethical open working environment.
Must be able to effectively multitask; with ability to prioritize and organize time restraints to effectively meet work timelines and strong attention to detail and deadlines.
Must possess clear, concise and persuasive writing and presentation skills.
Ability to make public presentations to individuals and groups for informational or other purposes.
Must possess strong Word Processing PC skills and ability to use a computer for modeling, analysis and inventorying of data; working knowledge of Microsoft Office Products.
Ability to educate self on healthcare compliance and accreditation standards and the latest quality techniques in health care.
Ability to effectively use research techniques and proposal development in order to critique proposals based upon program needs, funding source requirements and writing techniques.
Ability to complete study documents through outline, draft and final publication stages.
Ability to think conceptually, evaluate trends, analyze data and make recommendations.
Knowledge of the unique legal status of Indian Tribes, as well as sensitivity to cultural concerns.
Ability to deal with a variety of abstract and concrete variables.
QUALIFICATIONS, EXPERIENCE, EDUCATION
Minimum Qualifications:
- REQUIRED to possess a BA/BS Degree in health related or business related field; plus three (3) or more years of experience in health management positions with demonstrated compliance and quality skills. (Must submit copy of degree or transcripts with application.)
- REQUIRED to have knowledge of Medicare and Medicaid reimbursement and fraud abuse laws.
- REQUIRED to have knowledge of HIPAA regulations, the Privacy Act, Freedom of Information Act and other Federal and State requirements such as 42 CFR Part 2.
- REQUIRED to have knowledge of accreditation standards.
- REQUIRED to have computer experience, using word processing, database and spreadsheet software.
- REQUIRED to submit to a background and character investigation, as per Tribal policy. Following hire must immediately report to Human Resource any citation, arrest, conviction for a misdemeanor or felony crime.
- REQUIRED to submit to TB skin testing (as needed) and adhere to KTHFS staff immunization policy in accordance with the Centers for Disease Control immunization recommendations for healthcare workers.
- REQUIRED to accept the responsibility of a Mandatory Reporter in accordance with the Klamath Tribes Juvenile Ordinance Title 2, Chapter 15.64 and General Council Resolution #2005 003, all Tribal staff are considered mandatory reporters.
Preferred Qualifications:
A minimum of three (3) years management experience.
Indian Preference:
Indian and Tribal Preference will apply, as per policy. (Must submit tribal documentation with application to qualify for Indian Preference).
ACKNOWLEDGEMENT
This position description is intended to provide an overview of the requirements of the position. It is not necessarily inclusive and the job may require other essential and/or non-essential functions, tasks, duties, or responsibilities not listed herein. Management reserves the sole right to add, modify, or exclude any essential or non-essential requirement at any time with or without notice. Nothing in this job description, or by the completion of any requirement of the job by the employee, is intended to create a contract of employment of any type.
APPLICATION PROCEDURE
Submit a Klamath Tribal Health & Family Services Application for Employment with all requirements and supporting documentation to:
Klamath Tribal Health & Family Services
ATTN: Human Resource
3949 South 6th Street
Klamath Falls, OR 97603
IT IS THE RESPONSIBILITY OF THE APPLICANT TO PROVIDE SUFFICIENT INFORMATION TO PROVE QUALIFICATIONS FOR TRIBAL POSITIONS.
Please Note: If requirements are not met, i.e., submission of a resume in lieu of a tribal application or not including a required certification, your application will not be reviewed and will be disqualified.
Indian Preference will apply. In accordance with Klamath Tribal policy, priority in selection will be given to qualified applicants who present proof of eligibility for “Indian Preference”.
