Leadership Mentor

Leadership Institute Mentor Application ”A mentor is a contact person within the association who will assist in the development, teaching and coaching in their managed care specialty any AAMCN member who requests assistance. The Mentorship Program is one aspect of the Leadership Institute that fulfills its mission by strengthening our members’ leadership abilities within the healthcare environment.” I. Please fill out the below information and apply to be a part of our mentoring program!
Name:
Position/Title:
Credentials:
Address
City,State,Zip
Phone:
Fax:
Email:
Best Way To Contact You
II. Please indicate the area(s) in which you feel you would be a strong mentor:
	Leadership Fundamentals of Managed Care Utilization Management Disease Management Appeal Management Medicare/Medicaid Managed Care Career Guidance Administration/Management Patient Education Technology/Internet Reporting Research Quality Improvement/Performance Improvement Case Management Type:
III. Why are you interested in being a mentor? Please attach a brief paragraph of approximately 200 words answering this question. Please include your type of expertise, years of experience and capacity of work in managed care, other experience and accomplishments and a statement on why you feel you would make a good mentor?

**Mentor Requirements: Must be an AAMCN member in good standing; must be actively working in Managed Care with 3 to 5 years of experience in a specialty area; must submit a CV/Resume with this form. Please fax or mail this application and your CV/Resume to 804-747-5316 or 4435 Waterfront Dr., Ste. 101, Glen Allen, VA, 23060. Please call Patti Wilson at 804-747-9698 with any questions, or email to phulcher@aamcn.org.