Internal Audit & Consulting Services

Responsibilities of Internal Audit and Institutional Compliance

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