Health Information Management Privacy and Security Officer

AHIMA Foundation

Documents

Individual state requirements may vary. Please contact your local apprenticeship office to ensure this version is suitable to your state’s requirements.

Work Process Schedule

Work Process Content

On the Job Training

Anonymous

Skills

Maintains current knowledge of applicable federal and state privacy laws and accreditation standards.

Demonstrates understanding of HIPAA laws, standards and state privacy laws

Provides guidance and assistance in the identification, development, implementation, and maintenance of organization information privacy policies and procedures in coordination with organization management.

Coordinates the development of privacy risk assessment policies and procedures

Performs initial and periodic information privacy risk assessments and conducts related ongoing compliance monitoring activities. Participates in the development, implementation, and ongoing compliance monitoring of all trading partner and business associate agreements.

Conducts audits of internal and external privacy functions

Establishes a preventative program to detect, prevent and mitigates privacy/security breaches.

Develops performance measures and reports to monitor and improve organizational performance and report to appropriate organizational body.

Establishes an incident/complaint/breac h investigation response, develops response plan and oversees investigations of incidents/complaints/ breaches. Determines corrective action/remediation, sanctions and disciplinary actions.

Coordinates with the Corporate Compliance Officer or legal re: procedures for documenting and reporting any evidence of privacy violation

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.

Develop and implement a corporate- wide Privacy Training Program -- in conjunction with the Security Officer Oversight, Cyber Security Awareness & Training Program

Establishes a mechanism to track access to Protected Health Information (PHI), within the purview of the organization and as required by law.

Monitors Access and Disclosure Verification Procedures

Oversees processes to inspect, amend, and restrict access to protected health information when appropriate.

Provides support for organizational processes for use and disclosure of PHI including amendments, corrections, and accounting for disclosures

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.

Establishes and/or monitors an internal privacy audit program

Reviews 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.

Establish and monitor internal privacy and security audit programs

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 minimum necessary protocols, policies and procedures and legal requirements.

Periodically revise the privacy program in light of changes in laws, regulatory or company policy

Participates in the development and maintenance of the inventory of software, hardware and all information assets to protect information assets and to facilitate risk analysis.

Provides input to mitigate information security risk

Monitors advancements in information privacy technologies to ensure organizational adaptation.

Demonstrates current knowledge of information privacy technologies

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

Develops appropriate sanctions for failure to comply with the corporate privacy policies and procedures

Related Instruction Outline

Related Instruction Content

Training Provider(s):

Online and selfdirected

Online and selfdirected.

Online assessment

Online self-directed

WebEx

150

RI hours

Program orientation

Program overview

VLab tutorial

VLab training

Pre-immersion assessment

Retired CHPS exam questions

Read Chapters 1 and 2 in “Introduction to Health Information Privacy and Security” textbook and complete online assessments.

How health information is regulated, review of federal laws, state laws and accrediting and certifying bodies. Professional ethical standards and codes of conduct. HIPAA basics for privacy and security.

CHPS Domains 1 & 4: Ethics Regulation, Investigation and Compliance (H0EPCHPS14)

This course reviews the competencies of ethical, legal, and regulatory issues/external environment including investigation, compliance, and enforcement principles and strategies.

Read Chapters 3 and 6 in “Introduction to Health Information Privacy and Security” textbook and complete online assessments.

HIPAA privacy rule concepts to include use and disclosure, marketing and fundraising, and administrative requirements. Key changes under HITECH for privacy provisions.

CHPS Domain 2: Program Management and Administration (H0EPCHPS2)

This course reviews privacy and security program planning, including areas such as policy and procedure development, access authorization, and de-identification methods.

Read Chapters 4 and 5 in “Introduction to Health Information Privacy and Security” textbook and complete online assessments.

HIPAA security rule concepts to include physical safeguards, technical safeguards, organizational requirements and policies, procedures and documentation. Threat identification, risk analysis and disaster recovery/business continuity.

CHPS Domain 3: Information Technology/Physical and Technology Safeguards (H0EPCHPS3)

Learn best practices to develop and manage a strategic information security plan and implementing optimal technical safeguards including assessing security risks, identifying threats and vulnerabilities. Identify security requirements and appropriate measurements to protect the confidentiality and integrity of ePHI.

AHIMA Breach Management Toolkit

A comprehensive guide for compliance which addresses planning, implementing, and maintaining a breach management process.

AHIMA External HIPAA Audit Readiness Toolkit

Understand the requirements for HIPAA Phase 2 audits and guidance regarding audit preparation and practices.

Common employability modules

Common employability skills to include: • Communicating Effectively • Telephone Etiquette • The Mindful Leader • Leveraging Diversity and Strengths in the Workplace • Inspirational Leadership • Social Media Awareness • Excellence in Customer

Post-immersion assessment

Retired CHPS exam questions

Meetings with Coding Trainers

Review activities, provide feedback and instruction

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