Job Description
Job Description
The Claims Specialist – Franchise Network is responsible for managing, reviewing, and supporting all Medicaid and Managed Care claims submitted by franchisees operating under a Managing Services Agreement (MSA) with Texas Care. This role functions within the MSO structure and serves as the centralized point of oversight, technical support, and training for claims submission, billing accuracy, and reimbursement optimization across the franchise network.
The Claims Specialist does not provide direct clinical services and does not exercise control over franchisee employees. The role focuses on claims integrity, payer compliance, education, and operational support to ensure timely and accurate reimbursement.
Essential Duties and Responsibilities
Claims Management & Oversight
Manage and monitor all claims submitted on behalf of franchisees operating under an MSA.
Review claims for completeness, accuracy, and alignment with authorizations, service definitions, and payer requirements.
Track claim status across payers, including TMHP and Managed Care Organizations.
Identify trends in denials, rejections, or delays and implement corrective actions.
Coordinate claim resubmissions, corrections, and appeals as needed.
Franchisee Claims Support
Serve as the primary point of contact for franchisees regarding claims, billing questions, and reimbursement issues.
Provide technical assistance related to claim submission processes, authorization alignment, modifiers, units, and service codes.
Respond to franchisee inquiries in a timely and documented manner.
Training & Education
Develop and deliver claims and billing training for franchise owners, administrative staff, and billing personnel.
Train franchisees on MHR and TCM billing requirements, common billing errors, denial prevention, and claims workflows under the MSA model.
Support onboarding and refresher training for new and existing franchise locations.
Compliance & Quality Assurance
Ensure claims practices align with HHSC, TMHP, MCO, and Texas Care policies.
Support internal audits and payer reviews related to billing and claims.
Maintain documentation standards and audit trails for all claims activity.
Escalate potential compliance risks or systemic billing issues to leadership.
Reporting & Performance Monitoring
Generate regular reports on claims submitted, paid, denied, and pending.
Analyze denial trends, turnaround times, and aging to recommend process improvements.
Scope of Authority & Limitations
Manages and supports claims activities for franchisees under MSA.
Provides training and technical guidance related to billing and claims.
Does not make clinical determinations or alter clinical documentation.
Does not assume employer or HR responsibilities for franchise staff.
Does not independently set payer reimbursement rates.
Required Qualifications
Minimum 2–4 years of experience in medical billing, claims processing, or revenue cycle management.
Demonstrated experience with Texas Medicaid claims (TMHP preferred).
Familiarity with MHR and/or TCM billing structures.
Strong understanding of claims lifecycles, denials management, and resubmission processes.
Proficiency with billing systems, clearinghouses, and EHR platforms.
Preferred Qualifications
Experience supporting multi-site or franchise-based healthcare organizations.
Knowledge of Medicaid Managed Care Organizations.
Experience providing staff training or technical support.
Familiarity with MSO or centralized billing models.
Skills & Competencies
Strong attention to detail and organization.
Excellent written and verbal communication skills.
Ability to explain complex billing concepts in plain language.
Analytical mindset with problem-solving focus.
Ability to manage multiple priorities across franchise locations.
Performance Indicators
Claim acceptance and clean-claim rates.
Reduction in denial percentages.
Timeliness of claim submission and follow-up.
Franchisee satisfaction with billing support.
Disclaimer
This position provides claims management, training, and support services to franchisees operating under a Managing Services Agreement. Franchisees remain responsible for clinical service delivery and staffing.
Company DescriptionTexas Care is a leading behavioral health care organization and franchisor with a growing statewide network of clinics. We specialize in community-based mental health rehabilitation, targeted case management, and comprehensive support services. Our team is dedicated to ensuring consistent, high-quality care and compliance across all locations while staying true to our mission: Helping Texans Heal. We believe in empowering our staff to make a meaningful difference in the lives of the individuals and families we serve.
Company Description
Texas Care is a leading behavioral health care organization and franchisor with a growing statewide network of clinics. We specialize in community-based mental health rehabilitation, targeted case management, and comprehensive support services. Our team is dedicated to ensuring consistent, high-quality care and compliance across all locations while staying true to our mission: Helping Texans Heal. We believe in empowering our staff to make a meaningful difference in the lives of the individuals and families we serve.