PSN has nursing jobs in Case Management, Utilization Review and other areas of managed healthcare.

Home Staffing Solutions Accreditation Prep/Consulting Job Seekers About PSN, Inc.

PSN Application

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GENERAL INFORMATION

First Name *

Middle Name

Last Name *

Address *

City *

State

Zip

Home Phone *

Cell Phone

Fax Number

Email Address

In case of emergency, please notify (include full name and phone number)

EDUCATIONAL BACKGROUND

Level

Area/s of Concentration

PROFESSIONAL LICENSE

** Please specify license in the Clinical Specialty box

Background

Certifications

Licensure (Active States)

Clinical Specialty(ies)

License Number

Name/s formerly used on licenses/credentials (e.g., maiden name):

SKILLS AND EXPERIENCE

Clinical Criteria

Medical Coding

Computer

Other applicable skills/experience:

AVAILABILITY

Preferred hours/
employment status

Please describe the kind of work/environment you are seeking
and/or list the Job Number(s) of positions that interest you.

Did you indicate at least two supervisory references above? * Yes No

SUPERVISOR OR PROFESSIONAL REFERENCE

Supervisor Professional

Name of Reference:

Reference’s Title (at time of relationship):

Company Name:

Work Phone:

Home Phone:

Cell Phone:

Email:

City:

State

Dates of Employment

FROM

TO

I authorize this person to provide Professional Services Network, Inc. information regarding my work history and/or performance appraisal, and your company from all liability that might result from furnishing the information. * Yes No

VERIFICATION OF EMPLOYMENT

Company Name

Address

City:

State

Zip Code:

Phone Number:

Fax Number:

Dates of Employment

FROM

TO

I authorize this person to provide Professional Services Network, Inc. information regarding my work history and/or performance appraisal, and your company from all liability that might result from furnishing the information. * Yes No

Please attach current resume in either MS Word (.doc) or .txt format.

WHERE DID YOU LEARN ABOUT PSN?

Source

Name of source

OTHER QUESTIONS

Have you ever filled out an employment application for PSN?

Yes No

Have you ever had or have pending action taken against your professional license or certificate in any state of the Unites States? (Adverse action includes, but is not limited to: letter of warning, reprimand, denial, suspension, revocation, voluntary surrender or cancellation) *

Yes No

If yes, please explain. *

Within the last 7 years, have you pleaded guilty to, or been convicted of, any crime or violation of law?*

Yes No

Please explain. *

Many of our clients require a criminal background check, drug screen, proof of immunizations, including hepatitis B, negative TB test (within 12 months), and/or a physical exam (within 12 months) in order that you be considered for a temporary assignment at their office or hospital setting. Are you willing to undergo a criminal background check and drug screen and obtain the above health information if requested?

Yes No

Please explain. *

CONFIDENTIALITY AGREEMENT

Except as necessary to perform Managed Care review services (UR, QA, CM, Medical Record Review, Claims Review) I shall hold in strict confidence all information and material (written or verbal) provided by parties in the course of performing under this agreement. Confidentiality of information will include, and not be limited to, any individual or organization associated with corporations, insurance carriers, hospitals, physicians, nurses, other health care providers, and individual medical records reviewed.

I am aware that, during the course of my interview and/or contractual obligation, confidential information may be made available to me, such as employment openings, product designs, marketing strategies, customer lists, financial compensation and other related information. I understand that this information is proprietary and crucial to the success of Professional Services Network, Inc. (PSN) and its clients, and must not be given out or used outside of the PSN Agreement. In the event of termination of this Agreement, whether voluntary or involuntary, I hereby agree not to utilize or exploit this information with any other individual or company.

I agree that all materials or information created, assembled, distributed or otherwise communicated to me while performing under this agreement, including but not limited to data, designs, ideas, methods, reports, criteria or plans, are the sole property of PSN and/or its clients.

I agree that I shall fully disclose in writing, any interest, employment or association with any organization or corporation that may represent similar business interests as Professional Services Network, Inc. or its client companies. I understand that such interest may include a beneficial ownership of a corporation, or work as a director, officer, or employee of any organization, corporation, or association which may represent similar business interests in managed healthcare services and/or products as that of Professional Services Network, Inc.

I agree. *

I acknowledge that any false, incomplete, or misleading information I provide on this application form, in a resume, or in a pre-employment interview will be grounds to deny my application or, if discovered later, for immediate dismissal from employment.

I agree to this provision. *

EMPLOYMENT AT-WILL PROVISION

I acknowledge that this application is not meant to be a contract of employment and that my employment with Professional Services Network is AT WILL and may be terminated at any time with or without notice by either Professional Services Network or myself.

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