ACDIS Physician Advisor Mastermind application

The Mastermind group is a tightknit circle of eight to 10 handpicked physician advisors who commit to advancing concrete business goals and helping their peers do the same. Each meeting is facilitated by an ACDIS editorial team member management in collaboration with two Mastermind members in the "hot seat" to kick off the discussion at hand.

There’s no fee to join. Instead, members are selected based on a combination of their commitment to participate in regular meetings, share and receive advice generously, and/or make meaningful progress in their career.

Applications close at end of day Monday, December 2.

Selected members will be notified in December 2024.

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* 1. Please enter your contact information.

First Name *

Last Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 2. Eligible candidates must be licensed to practice medicine in the United States (MD or DO) AND currently serve in a physician advisor to CDI/UR/UM/Case Management role. Do you certify that both of these are true for you?

Yes

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* 3. What credentials do you hold? (Check all that apply.)

Doctor of Medicine (MD)

Doctor of Osteopathic Medicine (DO)

Certified Clinical Documentation Specialist (CCDS)

CCDS-Outpatient (CCDS-O)

American College of Physician Advisors Certification (ACPA-C)

American Board of Quality Assurance and Utilization Review Physicians, Inc. Physician Advisor Subspecialty Certification (CHCQM-PHYADV)

Fellow of American College of Healthcare Executives (FACHE)

Fellow of the American College of Physicians (FACP)

Fellow of the American Academy of Pediatrics (FAAP)

Bachelor of Medicine, Bachelor of Surgery (MBBS)

Other (please specify)

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* 4. What's the name of your organization?

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* 5. What is your current title?

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* 6. Please indicate your organization type.

Acute care hospital

Healthcare system with multiple sites

Outpatient/physician practice

Children's hospital/pediatrics

Critical access/rural healthcare

Rehab (inpatient or outpatient)

Home health

Long-term acute care

Consulting firm

Vendor organization

Other (please specify)

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* 7. Were you referred to the Physician Advisor Mastermind by someone?

Yes

If yes, please share the name of the person who referred you.

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* 8. In a paragraph or less, please share why you're interested in joining the physician advisor mastermind group.

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* 9. During meetings, mastermind members take turns in the “hot seat,” sharing a challenge or opportunity and describing the kind of input they'd like from their peers. Other members will then ask targeted questions, brainstorm strategies, and offer advice. Name two or three hot-seat topics you might bring to the table. (You can revise these at anytime.)

Topic 1

Topic 2

Topic 3

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* 10. How likely is it that you'll attend the following 2024 ACDIS events?

	Not likely	Somewhat likely	Very likely
2025 ACDIS Physician Advisor Forum, May 3-4 in in Kissimmee, Florida	2025 ACDIS Physician Advisor Forum, May 3-4 in in Kissimmee, Florida Not likely	2025 ACDIS Physician Advisor Forum, May 3-4 in in Kissimmee, Florida Somewhat likely	2025 ACDIS Physician Advisor Forum, May 3-4 in in Kissimmee, Florida Very likely
2025 ACDIS National Conference, May 4-7 in Kissimmee, Florida	2025 ACDIS National Conference, May 4-7 in Kissimmee, Florida Not likely	2025 ACDIS National Conference, May 4-7 in Kissimmee, Florida Somewhat likely	2025 ACDIS National Conference, May 4-7 in Kissimmee, Florida Very likely
2025 Physician Advisor Leadership Exchange (Note: This is an invite-only event, so we can't guarantee that all interested applicants will be able to attend.)	2025 Physician Advisor Leadership Exchange (Note: This is an invite-only event, so we can't guarantee that all interested applicants will be able to attend.) Not likely	2025 Physician Advisor Leadership Exchange (Note: This is an invite-only event, so we can't guarantee that all interested applicants will be able to attend.) Somewhat likely	2025 Physician Advisor Leadership Exchange (Note: This is an invite-only event, so we can't guarantee that all interested applicants will be able to attend.) Very likely

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* 11. To be considered for the mastermind group, you must attest to your ability to meet the minimum eligibility and participation requirements (outlined here). Will you be able to fulfill these requirements?

Yes