2024 Employment Application

Employment Application Form
I understand that ONLY applicants residing in Nebraska, Utah or Washington state will be considered for this position. If you do not live in one of these states, please do not apply as you will not be eligible to be considered. I live in:*

NebraskaUtahWashington
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Is it ok to text you?*

YesNo
E-mail*
Intstagram name:
Facebook name:
Date You Can Start*

MonthDayYear
Are you interested in:*

Full TimePart TimeEither
Please check the days of the week you are able to work during daytime hours:*

MondayTuesdayWednesdayThursdayFriday
At home, do you use:*

MacWindows
How many monitors do you currently have?*

123Laptop Only
Do you have a dedicated home office space with a desk?*

YesNo
Education:
What education do you have that is relevant to this position?*
Skills/Experience:
Do you have experience with the following (choose all that apply):*

IntakesSchedulingVerifying benefitsCredentialing & EnrollmentsCAQHMedical BillingResolving Claim DenialsUsing Simple PracticeGoogle SheetsAccounts Receivable
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Hourly Wage:*
Reason for Leaving?*
Start Date*

MonthDayYear
May We Contact for Reference?

YesNo
Contact Name:*
Contact Email:*
Contact Phone:*
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Hourly Wage:*
Reason for Leaving?*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Contact Name:*
Reason for Leaving?*
Contact Email:*
Contact Phone:*
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Hourly Wage:*
Reason for Leaving?*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Contact Name:*
Reason for Leaving?*
Contact Email:*
Contact Phone:*
Non-Family References (that you are ok with us contacting):
Reference 1*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Reference 2*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Reference 3*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
By submitting your application, you certify that all of the information provided is accurate and that if discrepancies are found, your application will be rejected or employment could be terminated.

Please also note: due to the sensitive nature of our responsibilites, this position will require a criminal background check. By submitting your application, you acknowledge and agree to the background check.

Other proficiency tests, such as spelling & grammar, typing, and billing skills may be required to be considered for employment.
Don't forget to send your introductory email and resume! Click Submit to Send Application:
Should be Empty:

Employment Application Form

Personal Information:

Education:

Skills/Experience:

Current Employment:

Previous Employment:

Previous Employment:

Non-Family References (that you are ok with us contacting):

Don't forget to send your introductory email and resume! Click Submit to Send Application: