Understanding the Role of a Privacy Officer in HIPAA Compliance

The designation and function of a Privacy Officer is an essential component of an organization’s compliance structure.

Definition and Mandate

The Privacy Officer is a legally required position within an organization handling Protected Health Information (PHI).

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This person must be a full time W-2 employee of the organization.

Core Responsibilities and Function

The Privacy Officer holds a central role in managing the administrative side of HIPAA compliance and ensuring the organization follows established policies and procedures. Key responsibilities include:

Compliance Leadership: The Privacy Officer (often alongside a Security Officer) leads the effort to organize policies, invite staff for training, conduct risk assessments, and manage third-party vendors.
Policy Management: They are typically responsible for ensuring that policies and procedures are drafted, reviewed, and customized to reflect the business's specific operations.
Administrative Oversight: The role involves managing employee and contractor policy attestation across the organization and overseeing staff onboarding and offboarding processes.
Audit Preparation and Support: The Privacy Officer takes ownership of key documentation needed for audits, such as the Security Risk Assessment (SRA). They also handle policy and procedure reviews, annual assessments, and compliance processes.
Incident Management: The Privacy Officer is often designated as the person responsible for leading the breach response and formalizing the documented process for incident reporting.
Compliance Expertise and Consulting: The Privacy Officer acts as the go-to resource for HIPAA-related questions and guidance.

Required Commitment

For organizations using a compliance platform, the designated Privacy Officer and other compliance leads must be prepared for the commitment involved:

Achieving initial HIPAA compliance
- Guided by Accountable, this can take ~10 hours of work
Completing a Security Risk Assessment annually
Ensuring BAAs are sent out and signed annually
Ensure team members are completing required trainings and attesting to policies & procedures annually
Updating policies & procedures, as needed
Handling incident response