Responsibilities of Internal Audit and Institutional Compliance
Institutional Compliance
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Internal Audit |
Coordinate updates to Handbook of Operating Procedures (HOP) |
Responsible for evaluating design & effectiveness of Compliance function |
Compare proposed HOP policies to federal regulations, System directives, etc. |
Develop long-range audit plan |
Provide guidance to departments & employees on policies & procedures |
Audit of new management areas to evaluate internal control system |
Coordinate external reviews with President’s Office and external federal agencies (not audits, i.e. ORI, HHS) |
Follow-up on significant findings from previous audit |
Annual risk assessment of compliance issues with input from key operational areas and key management positions |
Audit/review operational areas for stewardship of resources & compliance with established policies & procedures |
Designate management responsibilities for compliance as requested by the President |
Review internal administrative & accounting controls to safeguard resources & ensure compliance with laws & regulations |
Identify high-risk areas, and:
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Participate in manual & automated system design as an advisor on internal controls |
Meet monthly with key compliance areas, such as the IRB, Institutional Safety |
Investigate occurrences of fraud, embezzlement, theft, waste and recommends controls to prevent or detect such occurrences |
Monitor high-risk areas implementation of their monitoring plans by testing transactions and reviewing procedures |
Provides quarterly reports to UT System |
Evaluate specialized training sessions for content |
Coordinates activities of external auditors |
Prepared quarterly reports for Board of Regents on high-risk activities |
Facilitates Internal Audit Committee meeting |
Meet with the Board of Regents annually to review the institution’s compliance program |
Special audits/reviews requested by President or management |
Prepare and/or evaluate training materials and updates for the GCAT training sessions |
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Investigate hotline calls, anonymous letters. Discuss resolution of issues with Legal Affairs. |
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Answer concerns/issues of employees, vendors, affiliated hospitals |
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Develop policies & procedures from implementation of HIPAA privacy regulations |
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Organize working groups to address specific issues on campus. For example, after 9-11, groups formed to address resident processing, INS issues, volunteers and visitors |
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Special projects as requested by the President. For example, the processing of CareLink claims with UHS. |
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Address specific issues and concerns with UHS and VA compliance officers |
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Review billing/medical documents to ensure claims are properly coded |
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Train faculty, coders, UPG employees on specialty clinical documentation areas. |
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Conducted over 125 sessions last year |
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Monitor technical aspect of clinical research & patient consent and present findings to IRB |
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Facilitate Institutional Compliance Committee, and MSRDP Ethics & Compliance Committee meetings |