Apply for Nurse Care Manager

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Summary
Title:Nurse Care Manager
ID:1002
Location:N/A
Department:Nursing
Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security Number:
* Date of Birth:
Opt-In Confirmation
I authorize recruiters from Epic Nursing Services to send text messages from 8664856934 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Cover Letter:
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Acknowledgement Consent Form

OIG Consent Form

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that that Epic Nursing Services LLC, or its authorized agent will conduct an initial and monthly check of the OIG’s List of Excluded Individuals/Entities (LEIE). I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit such periodic checks for my information. This authorization is valid for the entire tenure of my employment with this organization. I consent to an OIG background check and affirm that the information provided on this Acknowledgement Form is true and accurate.
Yes
No

CORI Consent Form

* Epic Nursing Services LLC is registered under the provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I
hereby acknowledge and provide permission to Epic Nursing Services LLC to submit a CORI check for my information to the DCJIS. This authorization is valid throughout my employment tenure with the Agency.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
By consenting below, I provide my consent to a CORI check and affirm that the information provided is true and accurate.
Yes
No

Sex Offender Registry Investigation Consent

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that a Sex Offender Registry Investigation (SORB) will be submitted for my personal information. I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit a SORB check for my information. This authorization is valid throughout my employment tenure with the Agency.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
By consenting below, I provide my consent to a SORB check and affirm that the information provided is true and accurate.
Yes
No

Nurse Aide Registry Check

* As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that abuse checks will be conducted via the Nurse Aide Registry where my personal information will be submitted. I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit a NAR check for my information. This authorization is valid throughout my employment tenure with the Agency.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
Epic Nursing Services, LLC may conduct subsequent NAR checks throughout my employment tenure with the agency.
By signing below, I provide my consent to a NAR check and affirm that the information provided on this Acknowledgement Form is true and accurate.
Yes
No
* Signature

Driving Record Check Consent

* Date
* I hereby authorize Epic Nursing Services LLC and its designated agents and representatives to conduct a comprehensive review of my driving record through a consumer report and/or an investigative consumer report to be generated for insurance purposes.
Yes
No

Emergency Contact

* Emergency Contact Name
* Emergency contact Phone Number
* Emergency Contact Address
* Emergency Contact Relationship
Application For Employment
PERSONAL INFORMATION
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Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

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School 2

Yes   No

School 3

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School 4

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School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

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Yes   No
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Employer 2

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Employer 3

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Employer 4

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Employer 5

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REFERENCES

Please provide two professional references.

Reference 1

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Reference 2

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Reference 3

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AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

General Questions
* Are you authorized to work in the United States for any employer?
Yes
No
* Do you have a bachelors degree?
Yes
No
* Are you 18 or older?
Yes
No
* Would you be able and willing to travel as needed by the job?
Yes
No
* What minimum salary do you require?
* What type of job are you seeking?
Full-time
Part-time
Temporary or Seasonal

Emergency Contact

* Emergency Contact Name (First last)
* Emergency Contact Phone Number
* Emergency Contact Address
* Emergency Contact Relationship
Required Background Checks
As a prospective or current employee, subcontractor, volunteer, license applicant, or current licensee, I understand that that Epic Nursing Services LLC, or its authorized agent will conduct an initial Criminal background Check (CORI), Office of Inspector general (OIG), Sex offender Registry Board (SORB), and Nurse Aide Registry (NAR). Monthly checks of the OIG’s List of Excluded Individuals/Entities (LEIE). I hereby acknowledge and provide permission to Epic Nursing Services, LLC or its authorized agent to submit such initial and periodic checks for my information. This authorization is valid for the entire tenure of my employment with this organization. By signing below, I provide my consent to a CORI, SORB, OIG and NAR background checks and affirm that the information provided on this Acknowledgement Form is true and accurate.
* Social Security Number:
* Full Name:
* Date of Birth:
* Current Address:
* Signature:
* Date::
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
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Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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