Chief Quality Officer

Klamath Tribal Health and Family Services•Klamath Falls, OR

9d•Onsite

About The Position

The Chief Quality Officer has principal authority and responsibility for developing, implementing, overseeing, and evaluating all aspects of the Klamath Tribal Health & Family Services (KTHFS) Compliance Program. The role ensures compliance with applicable laws, regulations, and organizational policies and has direct access to the Governing Board and legal counsel to independently report compliance activities, risks, and corrective actions. The position reports to the Deputy Chief Executive Officer, who oversees performance. It also serves as HIPAA Privacy Officer for KTHFS and the Klamath Tribes, a hybrid entity, and performs complex administrative functions in support of KTHFS. The position oversees compliance and quality assurance/quality improvement activities, including audits, monitoring, investigations, corrective actions, regulatory interpretation, accreditation preparation, training, risk management, and reporting. It directly supervises the Quality Assurance Specialist and collaborates with organizational departments, committees, and leadership. The position is classified as Professional/Management, Regular, Full-Time, and is located at Klamath Tribal Health & Family Services in Klamath Falls, Oregon. The listed salary range is $87,713 to $153,806, with full benefits.

Requirements

Bachelor’s degree in a health-related or business-related field.
At least three years of experience in health management positions with demonstrated compliance and quality skills.
Knowledge of Medicare and Medicaid reimbursement and fraud and abuse laws.
Knowledge of HIPAA regulations, the Privacy Act, the Freedom of Information Act, 42 CFR Part 2, and other applicable federal and state requirements.
Knowledge of accreditation standards.
Computer experience with word processing, database, and spreadsheet software.
Experience with medical records and related requirements, including disclosure of information regulations.
Knowledge of HIPAA compliance and confidentiality requirements and ability to maintain strict confidentiality.
Ability to interpret accreditation standards, including Accreditation Association for Ambulatory Health Care standards.
Strong interpersonal and communication skills, initiative, decisiveness, professional judgment, and ability to work effectively with and motivate others.
Strong planning, organization, and time-management skills; ability to manage a diverse workload, multitask, prioritize, and meet deadlines with attention to detail.
Ability to work congenially with employees at diverse levels, handle conflicting viewpoints and pressure, and demonstrate discretion, integrity, and fair-mindedness.
Commitment to supporting an ethical and open working environment.
Clear, concise, and persuasive writing and presentation skills, including ability to present publicly to individuals and groups.
Strong word-processing and computer skills, including working knowledge of Microsoft Office products and ability to use computers for modeling, analysis, and data inventory.
Ability to learn healthcare compliance, accreditation standards, and current healthcare quality techniques.
Ability to use research techniques and develop proposals, evaluate proposals against program needs and funding requirements, and prepare study documents from outline through final publication.
Ability to think conceptually, evaluate trends, analyze data, and make recommendations.
Knowledge of the unique legal status of Indian Tribes and sensitivity to cultural concerns.
Ability to deal with abstract and concrete variables.
Submit a copy of the degree or transcripts with the application.
Submit to a background and character investigation under Tribal policy and report any misdemeanor or felony citation, arrest, or conviction to Human Resources immediately following hire.
Submit to TB skin testing as needed and comply with the KTHFS staff immunization policy and CDC recommendations for healthcare workers.
Accept mandatory reporter responsibilities under the Klamath Tribes Juvenile Ordinance and General Council Resolution #2005-003.

Nice To Haves

At least three years of management experience.
Eligibility for Indian and Tribal Preference, with tribal documentation submitted with the application.

Responsibilities

Directly supervise the Quality Assurance Specialist.
Oversee and monitor development and implementation of the KTHFS Compliance Program and Quality Assurance/Quality Improvement Plan and policies.
Improve organizational efficiency and service quality and reduce vulnerability to fraud and abuse through audits, communication channels, written standards and procedures, mock surveys, external audits, tracer activities, and policy coordination.
Develop, coordinate, and participate in compliance training for Governing Body members, employees, contractors, agents, consultants, volunteers, and others acting on behalf of KTHFS.
Provide HIPAA and privacy training during new-hire orientation and at regular intervals as needed.
Coordinate with Human Resources to ensure employees and contracted licensed independent practitioners are regularly screened against the Office of Inspector General’s List of Excluded Individuals and Entities.
Investigate reports or allegations of unethical or improper conduct or business practices, independently or with qualified legal counsel, and implement and monitor corrective action.
Direct corrective actions in response to potential non-compliance findings, including coordination with the Human Resource Director and/or Deputy CEO regarding discipline.
Audit programs, monitor compliance, track relevant laws and regulations, and identify indications of noncompliance.
Maintain compliance logs and requests, including HIPAA disclosure, complaint, patient complaint, incident report, and compliance concern logs; retain audit, inspection, license, and recertification documentation.
Coordinate with the IST Director on Business Associate Agreements and HIPAA Security Investigations.
Share responsibility for and oversee adverse incident and near-miss event risk management.
Collaborate with departments to prepare for external audits.
Monitor regulatory standards and applicable federal laws, develop and implement compliance action plans, interpret standards, and coordinate accreditation applications, site visits, and corrective actions.
Report Compliance Program activities quarterly to the Deputy CEO and compliance-related committees.
Draft compliance policies, communicate standards, maintain a compliance information repository, coordinate and monitor audits, oversee quarterly compliance committee meetings, investigate alleged misconduct, document compliance activities, and provide regulatory and compliance education.
Annually review and revise the Compliance Program as needed and oversee its implementation and monitoring.
Prepare for and/or conduct compliance site visits to provider locations and review audit work plans with staff to support implementation and service improvement.
Review and analyze assigned compliance requirements and grant programs and process implementation and annual reports of findings and future needs.
Participate in the KTHFS quality improvement committee and other assigned committees and meetings to support implementation of the organization-wide Quality Improvement plan.
Serve as HIPAA Privacy Officer and contact for HIPAA privacy complaints and violations; investigate alleged breaches of confidentiality involving protected health information and report findings to the Deputy CEO.
Ensure compliance with federal regulations, including 42 CFR Part 2, and provide initial and ongoing staff education on those requirements.
Work with the HIPAA Security Officer on HIPAA Security Rule implementation and documentation.
Perform administrative functions in support of KTHFS responsibilities.
Provide monthly activity reports and an annual report to the Deputy CEO, including trend data on reported incidents and completed training.
Assist with other Tribal tasks, including cultural, traditional, or community events, when needed; some tasks may occur outside regular work hours.