|
Institutional Compliance
|
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:
- Designate responsible party
- Assist area in developing monitoring plan
- Assist area in developing specialized training
|
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 |
|
|
Investigate hotline calls, anonymous letters. Discuss resolution of issues with Legal Affairs.
|
|
| Answer concerns/issues of employees, vendors, affiliated hospitals |
|
| Develop policies & procedures from implementation of HIPAA privacy regulations |
|
| 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 |
|
| Special projects as requested by the President. For example, the processing of CareLink claims with UHS. |
|
| Address specific issues and concerns with UHS and VA compliance officers |
|
| Review billing/medical documents to ensure claims are properly coded |
|
| Train faculty, coders, UPG employees on specialty clinical documentation areas. |
|
| Conducted over 125 sessions last year |
|
| Monitor technical aspect of clinical research & patient consent and present findings to IRB |
|
| Facilitate Institutional Compliance Committee, and MSRDP Ethics & Compliance Committee meetings |
|
