Navigating the J-1 Waiver Job Process and Obtaining a Position that Meets Your Career Goals

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For foreign national physicians, who reside, train and work in any country, there are distinct challenges that make finding the right job more complicated. My experience in the United States (US) has shown me that the visa process can be full of nuances and uncertainty that make navigating the application process difficult. To add to that, not all employers have the inclination, awareness or resources to assist or guide you in that process. Therefore, as a visa holder, it’s critical for you to be your own best advocate and arm yourself with the best information to navigate these circumstances. This blog aims to provide helpful information for making tough decisions in today’s complex and changing landscape of J-1 Physician Waivers.

 

I am a foreign national, did my residency training in internal medicine and joined a pulmonary and critical care fellowship. During this time, I needed to understand and negotiate the steps required to secure employment after completing my training. My residency program, like several others, only sponsored J-1 visas for foreign nationals and not H-1B’s. In the past, approximately 50% of incoming foreign national physicians were on J-1 visas and 50% were on H-1B visas. Because of the cost and extra paperwork involved in H-1B visas, most residency programs no longer prefer them. Given that we match into our training programs, the visa that we start with and remain on through the training process is also decided with that match.

 

J-1 visas are for foreign nationals who are approved to participate in work-and-study based exchange visitor programs. It is a visa meant for individuals who come to the United States to gain a new skill or knowledge that is required in the participant’s home country. Hence it comes with a ‘home country physical presence’ requirement. At this time, while training in the medical field, the J-1 visa can be extended for up to 7 years. While you are on a J-1 visa, you cannot apply for a permanent residency card (Green Card).

H-1B visas are for foreign nationals who have secured employment. It is a work-based visa meant for individuals with specialized skills that are in demand or required in the United States. It is usually for 3 years and can be extended for another 3 years after that. While you are on an H-1B visa, you are able to apply for your Green Card to continue living in the US.

A permanent residency card or a Green Card allows a non-US citizen to gain permanent residence in the US. Once a non-US citizen secures permanent resident status, they are able to live and work anywhere in the US without requiring visa sponsorship. After a few years (3-5 usually), they can apply for US citizenship status.

 

Step 1: Understand and define your specific circumstance

It is imperative to take into account your visa strategy while mapping out your professional trajectory during your residency. Your J-1 visa grants you a 7-year window from the inception of your training in the US. Upon completion of your training, you have several options for how to transition into your career:

1. The home country physical presence requirement:
To fulfill the ‘home country physical presence’ requirement, you can return to your home country for two years before seeking a new job in the US. Once you have completed this requirement, you can apply for a temporary work H-1B visa to work in the US. It's worth noting that there is an annual cap of 65,000 visas issued in the H-1B category, with an additional 20,000 visas available to those with a master’s degree from a US institution. There are a few situations that depend on your visa sponsor (employer) where your H-1B visa is not subject to this annual cap.

2. The J-1 Waiver:
An alternative to the ‘home country physical presence’ requirement is the J-1 Waiver. When you secure a J-1 visa waiver, you will be placed on an H-1B visa while you serve the three-year waiver terms in the US. The H-1B that you will be placed on during this time is not subject to the annual H-1B visa cap. Once you have completed your three-year service commitment in the Interested Government Agency (federal and state) waiver programs, ownership of the J-1 waiver and concomitant H-1B cap exemption belong to the J-1 physician regardless of the status of the next employer.

3. Other Visa Strategies:
You can also apply for other visa types like the F-1 (full time students), O-1 (exceptional ability, which generally requires demonstration of multiple publications as first or last author). This could give you the ability to remain in the US. so you have more time to plan your next steps. You are still required to complete the ‘home physical presence’ requirement or the J-1 waiver before you can move to a visa that allows you to apply for a Green Card.

4. Hardship and Persecution Waivers:
Two types of waivers which do not require employer sponsorship are the hardship and persecution waivers. If eligible, these waivers may be requested by the physician at any time during training and is a self-petition.

The best strategy depends on the individual and their set of priorities (eg, job requirements, location requirements, family responsibilities, J-1 visa holder’s available time to apply, employing institution’s strategy for hiring visa holders).

 

Step 2: Thoroughly investigate the requirements of available state and federal programs

The most popular state and federal programs used by graduating physicians to secure these J-1 waiver positions in the US are:

  1. The Conrad 30 program (notable differences in the way it is run by each state)
  2. The Delta Regional Authority (DRA) (dra.gov)
  3. The Appalachian Regional Commission (ARC) (arc.gov)
  4. Southeast Crescent Regional Commission (SCRC) (scrc.gov)
  5. Institutions under the Department of Veterans Affairs

These programs were initially created to help fill the need for physicians in medically underserved areas. The waiver programs most commonly use terms like Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), Medically Underserved Population (MUP), Mental Health Professional Shortage Area (MHPSA), to describe areas of need. (https://data.hrsa.gov/tools/shortage-area/by-address). These terms are only mentioned here, so you are familiar with them because they come up often when you are researching specific program requirements.

J-1 physicians who wish to waive their ‘home physical presence’ requirement, are encouraged to work in such designated areas with a greater need for healthcare professionals. Under the Conrad 30 program, many states have FLEX waiver spots for physicians agreeing to work in areas which are not designated as underserved, but serve individuals residing in neighboring underserved communities. Applications must be submitted by an employer. Depending on which program you apply through, each state has a fixed number of primary care and subspecialty positions and the split varies by state and by program.

The federal agencies which sponsor waivers, the ARC (HPSA areas only), the DRA and the SCRC are open year-round and can sponsor an unlimited number of waiver jobs within their geographic areas. There are no FLEX slots for federal waivers.

Caution: several websites host good information about each state’s Department of Health office but some information can be outdated. Be sure to call and verify or look for other sources if you are not receiving a response to your email queries.

 

Step 3: Understand timing

Most graduating fellows who are on an H-1B visa or do not require visa sponsorship, can wait till the last few months of their training to start looking for employment. Deadlines are different when you are on a J-1 visa and you require a state or federal program to process your application before you can step into the job of your choice. The most popular state program; the Conrad 30 program, accepts applications beginning September 1st, prior to the year of your graduation (the year before your program sponsored visa expires). These spots are filled on a first come first served basis. Within the Conrad 30 program, some states are extremely popular and receive enough applications to fill up all their open positions on day 1, while other states may never fill their 30 positions (this can be because the employers in the state generally do not offer enough J-1 visa waiver positions). Like we have mentioned above, the federal waiver programs listed, accept applications all year round.

There are the Departments of Health in each state which need to be considered. These departments can be robust and flexible in some states and can be overwhelmed and sluggish in others.

 

Step 4: Use social media

There are several resources online (Facebook, Reddit, etc.), none of which in my experience have all the information required but are a great way to crowdsource information to answer your own questions. Many of them can also generate good leads so keep an ear on the ground and explore recommendations from your peers who are also going through the process, or have been through it recently. These pages are also rife with unfounded rumors so be sure to confirm any claims personally or through a trusted source before believing it.

 

Step 5: Sign up for your licensing examinations

Most physicians have board examinations after the completion of training. Enrolling for these examinations will give you a bigger window to remain in the country legally, on your current visa and allow you a more comfortable timeframe to get all your paperwork processed and start your employment.

 

Step 6: Find an experienced physician immigration lawyer

Before you begin your job search, consult with an experienced physician immigration lawyer regarding your options.

Often the recruiting service that secured you the interview or the medical institution that is offering you employment will have in-house coordinators or work with physician immigration lawyers or government entities closely and are familiar with the J-1 physician waiver application process since they work with J-1 waiver candidates often.

If you choose not to consult a physician immigration lawyer upfront, I recommend going through the extra steps to ensure that the coordinator/lawyer has good prior experience with the actual process that is relevant to you and has not simply worked with general visa related cases. If you aren’t sure or are just not confident that they are the best team to represent you, reach out and secure an initial consultation with a recommended physician immigration lawyer who has experience with J-1 physicians and the J-1 physician waiver process. In my research the initial consultation could cost up to $500. After that, the cost for their services to complete the J-1 waiver application process is in the $6000 range. Because you are moved onto an H-1B visa when your J-1 waiver is approved, a legal team works with you to apply for the H-1B visa. This H-1B visa application process is usually paid for by the employer and also ranges in the $6000 range.

This is very important when you have secured a term sheet or work contract as well, especially since sometimes they work with the medical institution to include specific language that needs to be added into the work contract.

J-1 visa waivers mean that you will switch from a J-1 to an H-1B visa and are required to work for three years in H-1B status. Clarify if the person handling the application for your J-1 waiver will also help with the H-1B application which will follow as soon as you have received your J-1 waiver approval. If not, speak to the hiring institution about setting you up with an H-1B lawyer who can work with the J-1 waiver team to coordinate your visa application.

Lastly, you should think about speaking to your physician immigration lawyer about other possible visa pathways besides the straightforward J-1 waiver to H-1B, as some of these options may be a better fit for you when you consider the position, location and your own timeline.

 

Step 7: Securing a Job and a contract

Fortunately for our profession, physicians are in high demand with all the health care disparities, however finding the job you want, in the location that you want can be challenging. After detailed research, I recommend the following approach:

  1. Engage your personal and professional network. I cannot stress this enough. This can date back to medical school alumni, mentors from observerships, residency and fellowship and even personal family contacts who might be involved in health care. All you are looking for is an opening and a way to secure an interview; then you are off to the races. Mentors from your residency and fellowship are the best sources because they are actively working in the medical field that you are interested in and their contacts will be the most relevant. Institutions with fellowships and residencies of their own may prefer their own candidates and along the same lines people who you meet through a recommendation would prefer you over a stranger.
  2. Create detailed profiles on the several job search websites, speak to recruiters, go to job fairs and register with your current CV. Some of the websites also have the option to choose only results/matches with J-1 waiver eligibility. Doccafe, Practice link, Indeed, 3RNet, NEJM and subspecialty professional associations’ jobs boards are among the most used resources in this area.
  3. Your preferences should take into consideration not only the location that you prefer but also the research that you have performed over all the steps above.

 

Step 8: Red Flags and useful tips

During your job search, do not omit the crucial step of performing due diligence on the job, the employer and the community. Failure to do so could result in your taking a job for three years and having a miserable time.

Some of the red flags you should be aware of are the following:

  1. There are no other physicians in your specialty in the town.
  2. The employer wants to fly you into town under cover of night and out of town the next day. You should ask yourself what they are hiding by bringing you in on a Friday night and hastening your departure on a Saturday afternoon. You do not have the opportunity to meet the hospital administrators, many physicians or many staff members.
  3. If the employer wants you to sign the contract on the spot, this is a red flag. Why don’t they want you to take it home and review it with your lawyer?
  4. Few or no patients in the waiting room. This should lead to you asking where your patients will come from.

Tips to make better choices (especially in smaller cities/towns):

  1. Have breakfast at the local diner where the local people gather. You will be amazed at what you will learn about your community. The local people will ask a stranger entering their diner lots of questions. They are being friendly and will be happy to hear another doctor is coming to town.
  2. Ask to meet members of the medical community in an informal setting such as lunch or dinner. Failure to organize such a gathering is not only bad manners but may be an intentional barrier to prevent you speaking with doctors and other members of the medical community.
  3. Ask to bring your spouse with you to visit the community. If they care about hiring you, they should want to be sure your spouse likes the community too.
  4. Ask to meet members of the community such as politicians, religious leaders, bankers, real estate agents and school officials (if you have children). Again, this shows the employer cares about hiring you and that you care about the community you are considering.

Many questions will be community specific. Always go where they need and want you.

 

Step 9: Lean on your partner, friends, co-trainees, etc.

As we talked about at the beginning, this process is full of ups and downs and there will be several moments and situations where your determination and resolve will be tested. You will struggle to find the bandwidth to manage training, preparing for board examinations and conducting research to which you need to add this incredibly emotional and all-consuming process. You may feel alone because many of your peers may not know about what you are going through, many program directors and department chairs may not understand or may not have even heard of what the J-1 waiver process is. Such difficult times are better managed with people to lean on. So do not take them for granted.

 

A note for Program Directors

Your support to encourage and train J-1 visa candidates is of immense value. Foreign medical graduates and non-US citizens usually have the odds stacked against them because of their visa requirements and training programs’ preferences. These additional factors mean that fewer options are available to visa candidates not only for training but also in terms of employment.

Like in other spheres in our lives, a lack of awareness can create bias against such candidates and deprive them of necessary opportunities to succeed. There are countless examples of programs who are hesitant to match J-1 visa candidates because of the uncertainty of securing a visa, despite it being made a priority by US foreign policies and US embassies to ensure that delays do not occur. Similarly, there are employers who may not consider a worthy candidate because of their visa status or the additional resources that may be required to employ them.

The fact that you are in a position to mentor them and influence their career at this crucial juncture makes your awareness of these circumstances extremely important. Your references and the network that you are a part of, along with the spread of information such as this blog, can make all the difference in employing more candidates requiring a visa sponsorship. This could help improve healthcare disparities in the US, the success of your graduates’ after completing fellowship and strengthen your alumni.

 

Conclusion

The transition from a J-1 visa is complicated and involves several moving parts, none of which can begin until you have successfully secured an employment contract for an eligible position that satisfies your visa requirements. This is the part that you have the most control over, so start early, be proactive, use your network to its fullest and think about your most important priorities for the selection process. Once you have identified a strategy, think about legal representation. The process may always feel like an uphill battle but there are so many more options than there used to be that you should feel confident enough to look around, spend enough time vetting the program before signing the first option that comes across your desk.

After successfully securing a work contract, the subsequent steps involve several people and departments and a lot of this process is out of your control once it is set in motion so use the knowledge that you have gained along the way and remain available to help where you can and further your own cause.

 

Useful links:
  1. https://travel.state.gov/content/travel/en/U.S.-visas/study/exchange/waiver-of-the-exchange-visitor/eligibility.html
  2. https://www.U.S.cis.gov/working-in-the-united-states/students-and-exchange-visitors/conrad-30-waiver-program
  3. https://dra.gov/programs/human-infrastructure/health/delta-doctors/
  4. https://scrc.gov/programs/

 

Taaran Ballachanda, MD completed his residency training in internal medicine at Creighton University School of Medicine (Phoenix) and his fellowship training in pulmonary and critical care medicine at Rutgers New Jersey Medical School in Newark, NJ. He is currently an Assistant Professor at Hackensack University Medical Center within the Division of Pulmonary and Critical Care. He is part of the clinical academic faculty and mentors students from the Hackensack Meridian School of Medicine. His current clinical interests include use of point-of-care ultrasound, acute respiratory distress syndrome and use of extracorporeal membrane oxygenation. His long-term goals are to improve global healthcare equity by using technology to bring a sustainable supply of state-of-the-art medical care to parts of the world without economic security and inadequate infrastructure.

Jan Pederson heads Wright, Constable & Skeen’s Immigration Law Group. She has been recognized by The Washington Post as one of “seven leading lawyers” in Washington, D.C., due to her extraordinary achievements in the practice of immigration law. Ms. Pederson is masterful at resolving complex immigration issues and she has successfully represented thousands of clients, including physicians, Fortune 500 companies, television networks, journalists, entertainers, and healthcare providers. Jan was honored to receive the most prestigious national award for excellence in the advancement of immigration law, The Edith Lowenstein Award.

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