Healthcare Immigration

Our law firm often represents hospitals and other healthcare organizations in helping them sponsor their nurses, medical technologist, pharmacists, and other healthcare workers.  These days, given the backlogs for nurses, it can sometimes take years for an organization to sponsor a nurse for permanent residency.  The following is a general outline healthcare organizations can use to review their immigration options, as well as what is required to sponsor a foreign nurse.

Immigrant Visas (“Green Card”)

If the nurse resides in a foreign country, in order for her to work in the United States as a lawful permanent resident, she must:

  • Obtain a CGFNS certificate or full, unrestricted nursing license from the state of intended employment, or evidence that he/she has passed the NCLEX-RN licensing examination but cannot obtain a state license for a lack of a social security number;
  • Have a nursing diploma or degree; and
  • An RN license in his/her country.

Immigrant visas used to be readily obtainable for most RNs. However, since the Schedule A program expired, registered nurses have now been grouped into the employment-based third preference (EB3) category.  Even though employers are still not required to file a PERM labor certification with the DOL, processing times for nurses have significantly increased.  The length of time necessary for a nurse to enter the U.S. on an immigrant visa is determined, in part, by examining the processing times at the USCIS Service Center which services the region where the health care organization in which the nurse will be working is located. These Service Center processing times may be obtained by visiting www.bashyamspiro.com

The USCIS then sends the approved visa petition to the National Visa Center (NVC).If there is no backlog for immigrant visas from the RN’s native country (her “priority date ” is “current”), the NVC forwards instructions to the nurse or his/her attorney containing immigrant visa fee payment and information on the required documentation to be submitted to the NVC before processing can begin. Cable notification by the NVC and consular processing at the U.S. consulate abroad may take anywhere from two to six months to complete.

If the RN is already in the U.S., in valid nonimmigrant status and the RN’s priority date is ‘current’, he/she may be able to start working at a sponsoring health care organization. If the RN can meet certain statutory requirements set out in the Immigration and Nationality Act, Section 245, 8 U.S.C. Section 1255, he/she can become a lawful permanent resident without leaving the country to obtain an immigrant visa at a U.S. consulate. Moreover, by filing her immigrant petition and application to adjust status concurrently (if possible), he/she may be eligible for employment authorization within ninety days.

Although a Visa Screen certificate is not required to file the RN immigrant petition, it is required when the nurse is going through consular processing or adjusting of status (if in the United States).

Nonimmigrant Visas for Healthcare Workers

TN Status

Nurses from Canada or Mexico may be eligible to enter the U.S. pursuant to Trade NAFTA.  They may work in the U.S. in Trade NAFTA (“TN”) status by meeting the necessary requirements, paying a small fee, and engaging in an interview at the border (there is no requirement for filing any petition or application at the USCIS, thus there are no processing delays).

Canadian RNs may have a Canadian provincial license or a state license issued in the U.S. to qualify for TN status. The RN must have also obtained his/her Visa Screen, which is typically valid for 5 years. In addition, the RN must have a license to practice in the state of intended employment suitable for commencement of employment. Types of licenses which might qualify include a permanent license, a temporary license, or other temporary authorization, such as a letter or receipt for processing of the application for permanent license. The RN should also have an offer of employment from a U.S. employer and proof of Canadian citizenship.

TN status may be authorized for periods of up to three (3) years, but it may be renewed.

NAFTA also permits the entry of Mexican RNs, however the process is more complex. The steps involved to obtain TN status for a Mexican national include: approval by the Department of Labor of a labor condition application (LCA), approval by the USCIS of a TN petition supported by the approved LCA, and issuance by a U.S. consulate of a TN visa based on the approved petition. Mexican registered nurses must also possess a licenciatura degree and a Visa Screen.

H-1B Specialty Occupation

The H-1B visa category is reserved for foreign workers in “specialty occupations.” According to federal regulations, a “specialty occupation” is a position that requires theoretical and practical application of a body of highly specialized knowledge which requires the attainment of a bachelor’s degree or higher in a specific specialty, or its equivalent, as a minimum for entry into the occupation in the United States. This visa category is not a good fit for many RNs because a bachelor’s degree is not required for entry to the profession or to obtain licensure as a registered nurse.

Under the right circumstances, however, the H-1B may be appropriate.   The USCIS issued a memorandum that provided guidance on adjudication of H-1B petitions for RNs. The memorandum clarified that while typical RNs generally do not meet the requirements for H-1B classification, aliens in certain specialized RN occupations are more likely than typical RNs to be eligible for H-1B status.

In contrast to most general RN positions, the USCIS acknowledged that certain specialized nursing occupations are likely to require a bachelor’s or higher degree, and accordingly, be H-1B equivalent. The memorandum explains that positions that require nurses who are certified advanced practice registered nurses (APRN) will generally be H-1B equivalent due to the advanced level of education and training required for certification.

The memorandum describes certain advanced practice occupations that will generally be H-1B equivalent if the position requires, and the alien has obtained, advance practice certification. These positions include:

  • Clinical Nurse Specialists (CNS): Acute Care, Adult, Critical Care, Gerontological, Family, Hospice and Palliative Care, Neonatal, Pediatric, Psychiatric and Mental Health-Adult, Psychiatric and Mental Health-Child, and Women’s Health;
  • Nurse Practitioner (NP): Acute Care, Adult, Family, Gerontological, Pediatric, Psychiatric & Mental Health, Neonatal, and Women’s Health;
  • Certified Registered Nurse Anesthetist (CRNA); and
  • Certified Nurse-Midwife (CNM).

Certain other administrative nursing occupations, according to the USCIS memorandum, may also be H-1B equivalent. These positions include an upper-level “nurse manager” in a hospital administration position, since administrative positions typically require, and the individual must hold, a bachelor’s degree. Nursing Services Administrators are generally supervisory level nurses who hold an RN and a graduate degree in nursing or health administration.

Finally, the USCIS memorandum explains that an increasing number of nursing specialties, such as critical care and peri-operative (operating room), to name two examples, require a higher degree of knowledge and skill than a typical RN or staff nurse position. Certification examinations are available to RNs who are not advanced practice nurses, but who possess additional clinical experience. Examples of these types of certification examinations are school health, occupational health, rehabilitation nursing, emergency room nursing, critical care, operating room, oncology and pediatrics. In such nursing specialties, the petitioner may be able to demonstrate that the H-1B petition is approvable by demonstrating that the position meets the requirements for H-1Bs generally, and by demonstrating that the individual nurse meets the H-1B requirements.

Credentialing Requirements

CGFNS stands for Commission on Graduates of Foreign Nursing Schools. The CGFNS program is comprised of three parts:

  • Credentials review of the nurse’s education, registration and licensure;
  • CGFNS Qualifying Exam, a one-day qualifying exam testing nursing knowledge; and
  • English language proficiency exam.

Upon successful completion of all three elements of the program, the applicant is awarded a CGFNS Certificate.

The CGFNS Certification Program was created to serve as a predictor exam and evaluation process for foreign-educated nurses to more accurately forecast which nurses were likely to meet the requirements for licensure as registered nurses in the United States.

Credentials Review

GFNS evaluates an applicant’s education and registration credentials to certify that the applicant is a first-level, general nurse and meets all of the registration requirements to be licensed as a professional in that field.

Applicants must have completed a senior secondary school education separate from their nursing education; graduated from a government-approved nursing program of at least two years in length; and received theoretical instruction and clinical practice in nursing care of the adult (including medical and surgical nursing), maternal/infant nursing care, nursing care of children and psychiatric/mental health nursing. All transcripts are required to come directly from source agencies.

Applicants must have a full and unrestricted license/registration to practice as a first-level, general nurse in the country where they completed their general nursing education; and hold a current license/registration as a first-level, general nurse. All validations are required to come directly from the source agencies.

CGFNS Qualifying Exam

The CGFNS Qualifying Exam of nursing knowledge is offered three times a year at more than 40 locations around the world. The Qualifying Exam measures an applicant’s nursing knowledge and is based on what nurses must know and do when they practice nursing in the United States.

The foundations of the Qualifying Exam are based on client (patient) needs. The traditional clinical areas of nursing practice — nursing care of the adult, nursing care of children, maternal/infant nursing, psychiatric/mental health nursing and community health nursing — are covered. The exam ensures that an applicant has the same level of understanding of nursing with various client groups, in various settings, as recent graduates of U.S. schools of nursing.

Both the CGFNS Qualifying Exam and the NCLEX-RN® examination are based on the same framework of client needs because it provides a universal structure for defining nursing actions and competencies across all settings for all clients.

English Language Proficiency Exam

Applicants must demonstrate English language proficiency as part of the Certification Program by submitting passing scores from an approved testing organization. Currently, applicants may take either the Test of English as a Foreign Language (TOEFL), administered by the Educational Testing Service (ETS); the Test of English for International Communication (TOEIC), administered by the Chauncey Group; or the International English Language Testing System (IELTS), administered by Cambridge ESOL Examinations, the British Council and IDP Education Australia.

Applicants must successfully complete one of the English exams (TOEFL, TOEIC or IELTS) and the Qualifying Exam within a two-year period in order for test scores to be considered valid. The English exam may be taken prior to or following the CGFNS Qualifying Exam.

Foreign Registered Nurses applying to the Certification Program have the option to take

  • The Test of English as a Foreign Language, TOEFL 
    (administered by the Educational Testing Service ETS);
  • The Test of English for International Communication, TOEIC 
    (administered by the Chauncey Group); or
  • The International English Language Testing System, IELTS, 
    Academic Module (administered by Cambridge ESOL Examinations, 
    the British Council and IDP Education Australia).

For more information about the English Proficiency Requirements for the Certification Program click here.

Visa Screen – Visa Credentials Assessment

U.S. immigration law establishes the requirement of the Visa Screen certificate for foreign health care workers (other than physicians). The International Commission on Healthcare Professions (ICHP), created by the CGFNS, administers the Visa Screen. Applicants who successfully complete Visa Screen receive a Visa Screen Certificate, which can be presented to a consular office, or in the case of adjustment of status, the attorney general as part of a visa application.

The Visa Screen program is comprised of an educational analysis, licensure validation, English language proficiency assessment, and, in the case of nurses, an exam of nursing knowledge.

The educational review ensures that the applicant’s education meets all applicable, statutory and regulatory requirements for the profession the applicant intends to practice, and is comparable to that of a U.S. graduate seeking licensure.

In order to meet the educational requirements for the Visa Screen program, applicants must have:

  • Successfully completed a senior secondary school education that is separate from their professional education;
  • Graduated from a government-approved, professional healthcare program of at least two years in length; and
  • Successfully completed a minimum number of clock and/or credit hours in specific theoretical and clinical areas during their professional program. Country of professional education was Australia, Canada (except Quebec), Ireland, New Zealand, the United Kingdom or the United States.

The licensure review evaluates initial and all current and past licenses. Validations provided directly to ICHP by the issuing/validating institution, affirm that the applicant has completed all practice requirements and that the registration/licensure has no encumbrances.

The English language proficiency assessment confirms that the applicant has demonstrated the required competency in oral and written English by submitting passing scores on tests approved by the U.S. Departments of Education and Health and Human Services. Currently, to fulfill this requirement, applicants may take either the Test of English as a Foreign Language (TOEFL), Test of Written English (TWE) and Test of Spoken English (TSE), administered by the Educational Testing Service (ETS); or the Test of English for International Communication (TOEIC), administered by the Chauncey Group, along with the TSE and TWE, administered by ETS; or the International English Language Testing System (IELTS), administered by Cambridge ESOL Examinations, the British Council and IDP Education Australia.

Certain applicants may be exempt from the English language proficiency requirement if they meet all of the following criteria:

  • Country of professional education was Australia, Canada (except Quebec), Ireland, New Zealand, the United Kingdom or the United States;
  • Language of instruction was English; and
  • Language of textbooks was English.

Applicants who successfully complete the Visa Screen program will receive a Visa Screen Certificate. The Visa Screen Certificate, which satisfies all federal screening requirements, can then be presented to a consular office or, in the case of adjustment of status, the attorney general as part of a visa application.

Anyone with an interest in selecting highly-qualified, foreign-educated healthcare professionals for employment or education in the United States will find the program highly beneficial. Federal agencies, healthcare employers, academic institutions, health and education ministries, professional regulatory boards and international management companies all make use of Visa Screen or other ICHP evaluation services.

For more information about the CGFNS certification program, click here.

For more information about the VisaScreen Visa Credentials Assessment program, click here.

For more information on the NCLEX, click here.