DQA Specialist

Central-Ems; Conyers (GA); On-site; USD 52,000 - 68,000; Full time

Job summary

Central-Ems is seeking an Insurance Pre-Authorization & DQA Specialist to ensure accurate prior authorizations for EMS transports and high-quality documentation in PCRs.

The role links field operations, billing, and compliance to support compliant reimbursement. A strong background in EMS billing, medical terminology, and CMS requirements is essential for success in a fast-paced, office-based environment.

Qualifications

• High school diploma or equivalent required.
• Associate degree in healthcare administration, billing/coding, or related field preferred.
• 1–2 years of experience in medical billing, insurance, or healthcare administration preferred.

Responsibilities

• Verify insurance eligibility, benefits, and coverage for EMS transports.
• Initiate and obtain prior authorizations for scheduled transports.
• Document communications, approvals, and denials in patient records/billing system.
• Follow up on pending authorizations to prevent denials.
• Review PCRs for accuracy, completeness, and compliance with CMS/state regulations.
• Provide feedback to field crews on documentation improvements.
• Maintain QA logs and reports; support audits and compliance reviews.

Skills

EMS operations knowledge

Medical terminology

CMS requirements

Attention to detail

Communication skills

ePCR/billing systems

Education

High school diploma or equivalent

Associate degree in healthcare administration, billing/coding, or related field

EMT or Paramedic certification

Tools

Billing software

ePCR systems

CMS portals

Job description

Position SummaryThe Insurance Pre-Authorization & DQA Specialist is responsible for ensuring that all EMS transports requiring prior authorization are processed accurately and efficiently, and that completed patient care reports (PCRs) meet internal and regulatory quality standards. This role serves as a critical link between field operations, billing, and compliance to ensure clinical documentation supports appropriate reimbursement and maintains organizational compliance.Essential Duties & ResponsibilitiesInsurance Pre-Authorization Duties:Verify patient insurance eligibility, benefits, and coverage for EMS transports.Initiate and obtain prior authorizations for scheduled transports (e.g., non-emergency ambulance, repetitive transports).Communicate with hospitals, nursing facilities, insurance companies, and case managers to coordinate approvals.Document all communications, approvals, and denials in the patient record/billing system.Follow up on pending authorizations to ensure timely processing and prevent claim denials.Work with billing staff to resolve authorization-related denials or appeals.Data & Quality Assurance Duties:Review PCRs for accuracy, completeness, and compliance with company policies, CMS, and state EMS regulations.Ensure documentation supports medical necessity and aligns with billing/coding standards.Provide feedback to field crews on documentation errors, omissions, or opportunities for improvement.Assist in monitoring trends in documentation deficiencies and develop targeted education or corrective action.Maintain logs, reports, and metrics on QA/QI activities for internal compliance tracking.Support audits and compliance reviews by preparing requested records and reports.Working ConditionsOffice-based role with frequent computer and phone use.Occasional interaction with field staff and attendance at QA meetings.Standard weekday schedule with potential for flexible or extended hours based on operational needs.Knowledge, Skills, & AbilitiesKnowledge of EMS operations, medical terminology, and insurance billing practices.Familiarity with CMS medical necessity requirements and payer authorization processes.Strong attention to detail with the ability to identify documentation inconsistencies.Excellent communication skills to interact with insurance representatives, healthcare facilities, and EMS field staff.Proficiency in electronic patient care reporting (ePCR) and billing systems.Ability to manage multiple tasks, meet deadlines, and work in a fast-paced environment.Education & Experience RequirementsHigh school diploma or equivalent required; Associate’s degree in healthcare administration, billing/coding, or related field preferred.Prior experience in EMS billing, insurance authorization, or healthcare quality assurance strongly preferred.EMT or Paramedic certification (active or prior) a plus but not required.Minimum 1–2 years of experience in medical billing, insurance, or healthcare administration.