EMS Billing Specialist Application |

Hiring Processes

EMS Billing Specialist:

Application
Background Check
Oral Interview

Thank you for your interest in Mission Ambulance, Inc. By applying for a position with Mission Ambulance, you have just taken your first step towards finding the path to a satisfying career in EMS. Mission Ambulance is highly regarded throughout Southern California as being a forerunner in Courtesy, Compassion, and Commitment through professionalism and integrity.

A clear understanding of your background and work history will help us in placing you in the position that best meets your qualifications. It is our policy to provide equal employment opportunities to all qualified persons without regard to race, age, color, sex, religion, national origin, veteran status or physical handicap.

A complete Application must be filled out and screened in order to continue on to the next phase of the hiring process. If you meet the minimum qualification standards and pass the application screening process, you will be notified in writing or by phone.

Minimum Qualifications:

6 Months Experience Billing Medicare and/or Medi-Cal
Basic Medical Terminology
Computer Literate:
- Microsoft Word
- Microsoft Excel
Type 35 W.P.M.

Required Licensure and/or Certifications:

CA Driver License

Recommended Certifications:

Medical Billing Certificate
Medical Coding Certificate
Medical Terminology Certificate

[doc]Download a printable PDF version of this application[/doc]

AFTER SUBMITTING THE APPLICATION BELOW PLEASE RETURN BACK TO THE BEGINNING OF THIS FORM TO CONFIRM APPLICATION SUBMISSION OR CORRECT ANY ERRORS THAT MAY HAVE BEEN MADE DURING THE SUBMISSION PROCESS. IF THIS FORM IS NOT SUBMITTED CORRECTLY MISSION AMBULANCE WILL NOT RECEIVE YOUR APPLICATION.

EMS Billing Specialist Application

Personal Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Mailing Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Please enter your number formated as so: (###)###-####
Cell Phone
Please enter your number formated as so: (###)###-####
Pager
Please enter your number formated as so: (###)###-####
Email

Please enter your number formated as so: (###)###-####
Referred By
Employment Desired
Position
- Medical Biller
- Clerk
Status
- Full Time
- Part Time
Salary Desired
Start Date
Currently Employed
If yes, may we call current employer?
Have you ever applied here?
If yes when?
MM
DD
YYYY
Have you ever been previously employed by Mission Ambulance, Inc?*
If yes when?
MM
DD
YYYY
To
MM
DD
YYYY
General Information
Medical Billing Experience
- Medicare
- Medi Cal
- Share of Cost
- Private Insurance
- Workman's Comp.
- Other
If other please explain
Programs
- Word
- Exel
- Quick Books
- Medi Soft
- Other
If other please explain
General Clerical
- Type W.P.M
- Other
If other please explain
Office Specialties
- Accounts Payable
- Collections
- Accounts Receivable
- Customer Service
- Data Entry
- Filing
- Other
If other please explain
Education History
High School - Name
High School - Location
Street Address Address Line 2 City State ZIP Code
Yesrs
Did you graduate?
College - Name
College - Address
Street Address Address Line 2 City State ZIP Code
Years
Did you graduate?
Subjects
Technical School - Name
Technical School - Location
Street Address Address Line 2 City State ZIP Code
Years
Did you graduate?
Subjects
Employment History (Last 5 years, Starting with most recent)
From
MM
DD
YYYY
To
MM
DD
YYYY
Name of employer
Address of employer
Street Address Address Line 2 City State ZIP Code
Salary
Position
Reason for leaving
Employers phone
From
MM
DD
YYYY
To
MM
DD
YYYY
Name of employer
Address of employer
Street Address Address Line 2 City State ZIP Code
Salary
Position
Reason for leaving
Employers phone
From
MM
DD
YYYY
To
Name of employer
Address of employer
Street Address Address Line 2 City State ZIP Code
Salary
Position
Reason for leaving
Employers phone
Additional Skills and Training
Additional Skills and Training
References (names of people not related, whom you've known for at least one year)
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Years known
Name
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Years known
Name
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Years known
Authorization
"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."
- I understand the authorization conditions and agree

EMS Billing Specialist Application

Hiring Processes

EMS Billing Specialist Application

Personal Information

Employment Desired

General Information

Education History

Employment History (Last 5 years, Starting with most recent)

Additional Skills and Training

References (names of people not related, whom you've known for at least one year)

Authorization

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