Immediate Supervisor: Chief Executive Officer, Senior Executive, or Health Information Management (HIM) Department Head²

General Purpose: The privacy officer oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the healthcare organization’s information privacy practices.

• Provides development guidance and assists in the identification, implementation, and maintenance of organization information privacy policies and procedures in coordination with organization management and administration, the Privacy Oversight Committee,³ and legal counsel.

• Works with organization senior management and corporate compliance officer to establish an organization-wide Privacy Oversight Committee.

• Serves in a leadership role for the Privacy Oversight Committee’s activities.

• Performs initial and periodic information privacy risk assessments and conducts related ongoing compliance monitoring activities in coordination with the entity’s other compliance and operational assessment functions.

• Works with legal counsel and management, key departments, and committees to ensure the organization has and maintains appropriate privacy and confidentiality consent, authorization forms, and information notices and materials reflecting current organization and legal practices and requirements.

• Participates in the development, implementation, and ongoing compliance monitoring of all trading partner and business associate agreements, to ensure all privacy concerns, requirements, and responsibilities are addressed.

• Establishes with management and operations a mechanism to track access to protected health information, within the purview of the organization and as required by law and to allow qualified individuals to review or receive a report on such activity.

• Works cooperatively with the HIM Director and other applicable organization units in overseeing patient rights to inspect, amend, and restrict access to protected health information when appropriate.

• Establishes and administers a process for receiving, documenting, tracking, investigating, and taking action on all complaints concerning the organization’s privacy policies and procedures in coordination and collaboration with other similar functions and, when necessary, legal counsel.

• Ensures compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the organization’s workforce, extended workforce, and for all business associates, in cooperation with Human Resources, the information security officer, administration, and legal counsel as applicable.

• Initiates, facilitates and promotes activities to foster information privacy awareness within the organization and related entities.

• Serves as a member of, or liaison to, the organization’s IRB or Privacy Committee,⁴ should one exist. Also serves as the information privacy liaison for users of clinical and administrative systems.

• Reviews all system-related information security plans throughout the organization’s network to ensure alignment between security and privacy practices, and acts as a liaison to the information systems department.

• Works with all organization personnel involved with any aspect of release of protected health information, to ensure full coordination and cooperation under the organization’s policies and procedures and legal requirements

• Maintains current knowledge of applicable federal and state privacy laws and accreditation standards, and monitors advancements in information privacy technologies to ensure organizational adaptation and compliance.

• Serves as information privacy consultant to the organization for all departments and appropriate entities.

• Cooperates with the Office of Civil Rights, other legal entities, and organization officers in any compliance reviews or investigations.

• Works with organization administration, legal counsel, and other related parties to represent the organization’s information privacy interests with external parties (state or local government bodies) who undertake to adopt or amend privacy legislation, regulation, or standard.

This description is intended to serve as a scalable framework for organizations in development of a position description for the privacy officer.