Sample (Chief) Privacy Officer Job Description [2001]

Position Title: (Chief) Privacy Officer¹

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.

• Oversees, directs, delivers, or ensures delivery of initial and privacy training and orientation to all employees, volunteers, medical and professional staff, contractors, alliances, business associates, and other appropriate third parties.

• 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.

• Certification as an RHIA or RHIT with education and experience relative to the size and scope of the organization.

• Knowledge and experience in information privacy laws, access, release of information, and release control technologies.

• Knowledge in and the ability to apply the principles of HIM, project management, and change management.

• Demonstrated organization, facilitation, communication, and presentation skills.

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

Notes

1. The title for this position will vary from organization to organization, and may not be the primary title of the individual serving in the position. "Chief" would most likely refer to very large integrated delivery systems. The term "privacy officer" is specifically mention in the HIPAA Privacy Regulation.

2. Again, the supervisor for this position will vary depending on the institution and its size. Since many of the functions are already inherent in the Health Information or Medical Records Department or function, many organizations may elect to keep this function in that department.

3. The "Privacy Oversight Committee" described here is a recommendation of AHIMA, and should not be considered the same as the "Privacy Committee" described in the HIPAA privacy regulation. A privacy oversight committee could include representation from the organization's senior administration, in addition to departments and individuals who can lend an organization-wide perspective to privacy implementation and compliance.

4. Not all organizations will have an Institutional Review Board (IRB) or Privacy Committee for oversight of research activities. However, should such bodies be present or require establishment under HIPAA or other federal or state requirements, the privacy officer will need to work with this group(s) to ensure authorizations and awareness are established where needed or required.