Chief Quality Officer

Description

OPEN: 10/16/2026

CLOSE: UNTIL FILLED

POSITION DESCRIPTION

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 operat