Classification: EXEMPT | Status & Schedule: FULL-TIME, MONDAY – FRIDAY, 8AM – 5PM
Location: ONSITE,  Reports to the North Bend office, requires travel to other Waterfall sites  

Salary: $65,000.00 - 85,000.00/ANNUALLY
Department: QUALITY & COMPLIANCE | Reports to: Chief Executive Officer, direct reporting line to the Board of Directors | Supervision Exercised: SUPERVISORY- HIMS Staff

The Compliance Officer oversees Health Information Management (HIM) and the Compliance Department, ensuring a robust compliance program that meets HRSA requirements and federal/state regulations. Serving as Compliance and Privacy Officer, this role provides leadership and oversight for medical records management, HIPAA compliance, risk management, and regulatory reporting. 

Reporting to the CEO and Board of Directors, the Compliance Officer establishes and maintains departmental policies and procedures to ensure workflow quality, operational effectiveness, and regulatory compliance. This role manages the organization’s health information systems, supports quality assurance and compliance reporting, and responds to internal and external requests for patient records. The Compliance Officer may also lead projects to implement or enhance electronic medical records (EMR) and ensures accurate data collection for compliance and risk management purposes. 

Essential Responsibilities: Compliance Department Administration 

1. Provider oversight, direction, and leadership for the Health Information Department and HIM Staff 
2. Oversee and manages all aspects of the medical records life cycle, including but not limited to requests for release of information, death certificates, POLST submissions, digital faxes, and requests for medical records, in accordance with state law and HIPPA 
3. Ensure accuracy, completeness, and security of patient medical records, overseeing applicable Electronic Health Record (EHR) system areas and data integrity 
4. Develop, maintain, and administer HIM, Privacy, and Compliance policies and procedures 
5. Manage record retention, indexing, and document imaging 
6. Develop, implement, and monitor the organization’s compliance program, coordinating compliance activities in line with guidance from the Office of Inspector General 
7. Ensure compliance with federal and state healthcare regulations 
8. Investigate potential compliance violations and recommend corrective actions 
9. Provide compliance training to employees 
10. Maintains working knowledge of HIPPA rules and regulations and disseminates information as appropriate, applying to day-to-day operations 
11. Independently review and evaluate compliance issues and ensure appropriate departmental collaboration in investigation and resolution, including consultation with General Council to resolve complex legal compliance issues 
12. Identifies potential areas of compliance vulnerability and risk, implements action plans for resolution, provides guidance on how to avoid similar situations in the future 
13. Performs Compliance and Risk Management investigations and internal audits, providing recommended course of action to mitigate risk; provides regular compliance and risk management reports to Executive Leadership and the Board 
14. Ensure integrity of project data by auditing results and providing to applicable managers for appropriate action 
15. Participate in, and/or facilitate internal committees as directed, including the Quality Assurance (QA)/Quality Improvement (QI) Committee, and Health and Safety Committee
16. Provides the required documentation to support FTCA redeeming application for submission 
17. Facilitates WCHC Privileging process, following Board adopted policy 
18. Acts as point of contact for patient complaints and grievances, including FTCA complaints 
19. Reporting claims and potentially compensable events (PCE’s) to the appropriate entity, including medical malpractice insurance providers or U.S. Department of Health and Human Services Federal Tort Claims Act (FTCA) claims (as appropriate) and other insurers in accordance with the requirements of the insurance policy/contract and FTCA 
20. Adhere to the spirit of Waterfall Community Health Center to remove barriers to care and our mission statement while performing assigned duties 
21. Ensure compliance with company policies and procedures as applicable to area(s) of responsibility 
22. Handle confidential information and materials appropriately and maintain a secure work area 
23. Other duties as assigned 

 Essential Responsibilities: ORGANIZATIONAL TEAM MEMBER 

• Participate in quality and organizational process improvement activities when requested 
• Support and contribute to effective safety, quality, and risk management efforts by adhering to established policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities 
• Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner 
• Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization 
• Provide excellent customer service to all internal and external customers, which includes team members, patients, students, visitors, and vendors, by consistently exceeding the customer’s expectations 
• Advance personal knowledge base by pursuing continuing education to enhance professional competence 
• Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards 
• Represent organization at meetings and conferences as applicable  

Essential Responsibilities: PERSONNEL MANAGEMENT 

• Plan, orient and assign work to personnel that supports goals and objectives contained in the organization’s Strategic Plan and delivers outstanding team-based services 
• Promote a culture of risk-management, team-based, values-based, high-performance, and continually improving practice that values learning and a commitment to quality 
• Establish and monitor assigned staff performance, assign accountabilities, set objectives, and establish priorities 
• Assist in the recruitment, hiring, orientation, development, and evaluation of assigned staff, including the completion of Performance Reviews and merit wage adjustments 
• Promote employee retention, productivity, and satisfaction through ongoing support, encouragement, empowerment, coaching and effective teamwork 
• Ensure staff comply with approved organizational policy and procedure 
• Knowledge of federal and state employment and labor laws 
• Assist employees to read, interpret and apply policies and procedures 
• Support and mobilize assigned staff to engage in their assigned work through implementation of team building, performance coaching and problem-solving strategies 
• Ensure staff are cross-trained to accomplish the goals and objectives of the organization  
• Responsible to back-up assigned staff workloads when necessary  
• Respond to the needs of direct and indirect staff with clear, open, and honest communication, mutual respect, and consistent follow through to generate trust and enhance personal effectiveness 
• Recommend discharge of employees, when indicated, based on work performance and behaviors 

Working Conditions: (Administrative/Office Clerical) 

This position must have the ability to remain in a stationary position, often for long periods of time, and occasionally move about inside the office to access office machinery; and frequently communicate and exchange accurate information. 

Work Condition: Healthcare Facility 

• Employee generally works within the interior of a healthcare facility office. 
• Employee may travel locally and be responsible for own transportation; out of area travel may be required on occasion. 
• Hours of operations and specific staff scheduling may vary based on operational need. 
• The healthcare facility office environment is clean with a comfortable temperature and moderate noise level.  
• TB test upon hire.  

Exposed to:  

• Healthcare facility cold and heat controls. 
• Close contact with employees and the public, in a healthcare facility. 
• Potential exposure to communicable diseases. 
• Potential exposure to escalated or angry patients. 

Machines, equipment, tools, and supplies used:  

• Constantly operates a computer and other office productivity machinery, such as postage machine, fax, copier, calculator, multi-line telephone system, scanner. 
• May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information. 
• May be required to use standard precautions due to threat of exposure to blood and bodily fluids. 

Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task. 

  Education, Experience, and Qualifications: 

• Associate’s or Bachelor’s degree in Health Information Management or related field 
• Healthcare- Compliance and/or Privacy and Security Certification(s), or willing to obtain 
• Three to five years of experience in HIMS management (electronic and paper records), Compliance or Privacy in a healthcare organization, specifically with electronic health record (EHR) management, OCHIN EPIC experience a plus 
• Healthcare auditing and investigative experience required 
• Non-violent Crisis Intervention Comprehensive training class completed within 6 months of hire and recertification prior to expiration date 
• Current American Health Association (AHA) Basic Life Support Card (BLS) within 6 months of hire and recertification prior to expiration date 
• Mandatory Trainings for Organization and Advanced Health compliance completed within 3 months of hire, no later than 6 months, and recertify prior to expiration date 
• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) Certificate strongly preferred