Searching in California

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With my assignment in Washington ending, I took some time off to be home for the holidays. In the mean time, I began my search for my next assignment. I was hoping to go to Texas, but there did not seem to be many options available.

On the other hand, now that I had a California license, I was quickly overwhelmed by how many options there were in California. At first I was open to working anywhere in California. Yet, it is a gigantic state so I realized I had to limit my search.

Since Northern California gets pretty cold during the winter, I decided I wanted to work in Southern or Central California for my next assignment. I am credentialed with a handful of agencies and notified them about my search criteria. Every day there was a new job available in which I had to yay or nay.

During the interview process, I noticed that my expectations for which facility I was going to work with were pretty high. This was because I had truly enjoyed my experience working in the community health center in Washington. I said no to facilities that didn’t meet my needs. Examples were clinics that were still using paper charting; clinics that treated majority chronic pain and substance abuse; clinics that only needed a provider for 30 hours per week etc.

Although I was grateful for many options, I found myself feeling anxious because there were too many that were similar. It was difficult for me to narrow them down. There are several factors involved in selecting an assignment: location, type of facility, hours (four 10 hour shifts vs M-F 8 hour shifts), pay, housing options, and other incentives.

I was straightforward with my recruiters in letting them know that I was working with other agencies and considering other options. Most of them were understanding, while a few were spiteful. Towards the end of my search process, I had over 15 potential gigs. I had already completed my interviews with all of the sites and they were each willing to make me an offer.

I ended up choosing two sites by the end of my search. I chose one of them because the timing worked out (it started before the other assignments did). Also, the facility seemed similar to the site I worked in Washington (based off of my phone conversations with the providers there). The second site I selected because it was in my ideal location.

I think in the future I will be more specific about my needs in California, so as not to have more than enough options and overwhelm myself again. I believe a handful of options are great but more than 5 can be extreme.

CA License Part 2

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I previously wrote about finally obtaining my California license and being ecstatic about it. It ended up still being a bit of a hassle because the CA furnishing license took another 4 weeks. On top of that, CA board of nursing required me to take a 3 hour continuing education course on scheduled II controlled substances through the California Association of Nurse Practitioners. Luckily, the agency I was working with paid for the course which cost $250.

The course itself was pretty easy and straightforward. It consisted of reading powerpoints and pdf documents at your own pace. Then I had to take a short test on what I had read. Once I passed the test, I submitted the certification to the CA BON. They had provided me with a fax number to submit a copy of the certification.

I was impressed with my licensing coordinator from the agency because as soon as I faxed it over, she already called to make sure her contacts there input the information. Within 1 hour she had called me to tell me the CA BON changed my furnishing license to allow scheduled II’s to be prescribed, and the DEA has already provided her with my new CA DEA.

Those of us that have obtained or are in the process of obtaining a CA license know how slow the CA BON of works, and how difficult it is to get in contact with someone there. If you plan on working in California, make sure you allow an ample amount of time to obtain your license.

Contracts

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Upon accepting an assignment, it will not be official until a contract has been created. Most agencies will send you a written contract for you to review and sign within a brief time frame after verbally accepting an assignment.

Some agencies use verbal contracts in which they review the terms of the contract and you will verbally agree to the terms. You may request to have a written copy submitted to you afterwards.

Sometimes an agency may review the terms of the contract with you over the phone, and then send you a contract that states no signature is needed because the receipt of the contract is binding.

I am sure like most people, I personally prefer written contracts I can sign. It gives me the chance to think about the assignment and the conditions agreed upon before having to sign the contract, and making it official.

However, as noted above, there are different methods of contract agreements. Be sure to ask your recruiter which type they use. I know many locum tenens nurse practitioners, including myself, that have found themselves “bound” to a contract they were not aware of.

Be straightforward with your recruiter that you will not consider the assignment official until you have a contract in place and have agreed to it after receiving it. In my case, I was emailed a contract that was binding upon receipt. Meanwhile, I didn’t think it was official since I had not signed it. When I was contacted by credentialing and their traveling team, I then realized that they assumed I was going forward with that assignment because they sent me a contract.

After a site determines that they want you, your recruiter may ask you if you want to accept the assignment. Sometimes we find ourselves saying yes before we are completely sure. Then a few days later you may change your mind and notify your recruiter. Often, they are upset by your new declination because now they have to inform the site. Technically, if they never sent you a contract or you had not yet signed it, you have the right to change your decision.

What should your contract include?

Everything agreed upon by you and your recruiter should be stated in the contract. This includes your hourly pay rate, overtime rate, exact time frame of assignment, and your general weekly schedule. The contract should state your travel and lodging will be covered, whether it is a rental car and flight, or providing you round trip mileage reimbursement. If your license costs are supposed to be covered, that should be in the contract. Other things that should be in the contract if indicated are sign-on bonuses, W2 benefits, DEA license fee reimbursement, and/or scheduled vacation days.

One of the most important things I look for in a contract is the “breaking of a contract” section. Most agencies will include the typical 30 days notice section, that states you must provide 30 days notice before leaving a site. Some contracts will state penalties for leaving before 30 days such as forfeit of pending paychecks and being responsible for your own travel back home. These things can be negotiable so make sure to read the contract closely before signing or agreeing to the terms.

Alternative Pay

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When looking for a locum tenens assignment, we frequently only think about hourly pay. From my experiences and talking to other traveling nurse practitioners, there can be other monetary incentives.

Some agencies will provide a sign-on bonus for a very high-need site. The sign on bonus can range from several hundred dollars to several thousands of dollars. For example, I know a nurse practitioner that accepted a locums position in South Dakota with a sign-on bonus of $1000. The reason they provided her with a bonus is because it is challenging recruiting someone for that particular state. Typically, the bonus is provided in divided amounts throughout the length of the assignment, to make sure you don’t just accept the bonus and give your 30 days notice.

Moreover, there are agencies that will provide you with a weekly stipend or a daily per diem to cover extra expenses. For instance, to cover the cost of your license indirectly, they may give you $100 a week as a stipend, which in the long run is more than the cost of the license. Or they may give you a $30 per day per diem, to help cover costs of meals and gas. Keep in mind that per diems are tax-free! Imagine having an extra $600 a month at your disposal.

Finally, I have seen a variety of “holiday pay”. If you elect to work on a holiday workday, you are entitled to time and a half. Government focused locum tenens agencies will pay you for federal holidays even when you do not work because the site is closed. This can be pretty substantial.

Some recruiters may laugh at you when you tell them your expected hourly rate or that you need your DEA cost covered. Do not settle for one “no”. One agencies’ “no”, may be another agencies’ “yes”. If the site really wants you, the agency needs you, and they are willing to do whatever it takes to get you out there!

Conflict in Locum Tenens Workplace

For the most part, I have enjoyed my experiences working in locum tenens. However, like any other workplace, there can be some internal conflict. I would like to share a couple of experiences with this and my purpose for sharing them.

During one site I worked for, the scheduling was often irregular, and there would be times that the clinic was over staffed. The patients were only walk-ins so no appointments were made prior. One day, instead of taking turns seeing patients, the other provider assumed that since I was the locums provider, I should be doing the majority of the work.

Each time a new patient came, she had the medical assistant place the patient under my profile. Sometimes she would ask the patient why they were there, and give me a brief overview of the patient, instead of seeing them herself. At first I did not mind since I prefer to be busy than bored. Yet, after seeing 12 patients on my own, and her seeing 0, I decided to confront her.

Instead of asking “why aren’t you seeing any patients?” I jokingly said “Ok you can see the rest of the patients for the day”. She simply said “ok”. And guess what, she saw the remaining 9 patients of the day!

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During another site I worked in, I had a different dilemma. In this instance, I had treated a provider’s patient for sinusitis the week prior. The following week, I had a message waiting for me on my EHR from the nurse practitioner stating: “For your information, the Z-pack is no longer the drug of choice for sinusitis. It is augmentin.” When checking the patient’s chart, I noticed they were allergic to penicillin (this derivative is in augmentin), which reminded me why I chose to treat the patient with the Z-pack. I responded to the provider stating: “Yes, I know. The patient is allergic to penicillin which is why I chose to give the Z-pack over augmentin.” The provider responded with “Ok, I see that now.”

I was super annoyed with that message because 1. I knew what I was doing; 2. The provider should have checked the patient’s chart before messaging me; 3. It was a sinus infection! The treatment isn’t nearly as significant as diabetes or hypertension. 4. I had the utmost respect for this nurse practitioner until he decided to scrutinize my care for his patients; and lastly 5. I have a few more years of experience as a nurse practitioner than he does.

My point is, although most of your coworkers during a locums assignment will be happy to have you there (and the help), some may take advantage. Do not let them abuse you or question your skills! Be confident in who you are as a provider, offer to help as needed, and make sure everyone else is playing fair. Unfortunately, we all know workplace violence is quite common in the medical field. Do not let it go unnoticed and stick up for yourself!

W2 vs 1099 Pay

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I am constantly being asked questions about pay rates for locum tenens nurse practitioners and the difference between W2 and 1099. I decided to write a post about these different pay options.

Everyone’s situation is different so I cannot say one is better than the other regarding W2 vs 1099. I do know that a lot of people automatically think W2 is better because you don’t have to worry about your taxes at the end of the year, and they provide benefits such as health insurance.

Although W2 agencies take out taxes from your paycheck and provide benefits, they tend to pay way lower than 1099 agencies. I have seen the same job being offered by a W2 agency and a 1099 agency with a $10/hour difference. When being offered health insurance, they also tend to deduct another $3/hour from your pay rate to pay for the health insurance. If you choose to pay for health insurance out-of-pocket, you typically are only spending $1/hour of your pay on private insurance, and you get to deduct it at the end of the year when filing your taxes.

Personally, I prefer 1099 because of the higher pay rate. Also, since you are technically self-employed you can deduct a lot of items that will lower your overall taxes. Based off of experience, I think the mixture of working with some W2 agencies and some 1099 agencies is optimal. The reason for this is because the taxes taken out with the W2 position, and owed with the 1099 position will often balance each other out.

I do not choose an agency based off of pay type, instead I choose an agency based off of the job options they can present to me. I usually narrow it down to a handful of agencies, and choose the best job from there, despite them being W2/1099.

Timing

I have had several readers ask me questions about the time frame of searching for an assignment. How soon should we start searching? When should we begin getting worried if we haven’t yet found an assignment?

Sites generally are looking for someone to start as soon as possible. Therefore, I recommend beginning your search process 1-2 months before your ideal start date (if you already have the state license). It may take several weeks for something to become available that meets your criteria. As I have mentioned before, I always recommend working with more than one agency so you can increase your chances of finding the right assignment.

If you are 1 month away from your ideal start date, I recommend expanding your focus. This may mean being open-minded about the location; anywhere in the state vs just one city as an option. Or this may mean being open about the time frame; consider a longer time frame than the typical 3 months. You should also start consulting with other agencies you haven’t connected with yet.

Once you find an assignment you do like, the interview process can range from same-day interviews to 2 weeks. Then the site sometimes needs a second interview, or several days to make a decision (if they have other interviews or need to have a staff meeting about budget etc.).

Always inquire about the credentialing time frame. Each site is different and credentialing may vary from 1 day to 3 months. So if you are 1 month outside of your ideal start date, and the sites credentialing can take up to 2 months, you may want to consider other options.

Definitely, do not wait until the last-minute to find a position unless you are open to anything and anywhere. Sometimes recruiters will tell you that credentialing is quick, so in your mind you think you can start right away. I would definitely factor in about 2 weeks for credentialing for the majority of assignments. I would factor in 1-2 weeks for interviews and 2-4 weeks for the searching process. This is why I recommend searching about 2 months before your ideal start date.

5 Tips to begin Locum Tenens

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  • Do your research: Research which places you would like to practice in. Are you willing to travel? Do you only want to practice locally? Are you interested in working in a state with full practice authority? During your initial conversation with a recruiter, they always want to know where you are interested in working.
  • Identify agencies you would like to work with: Do you prefer to be paid via W2 or 1099? Do you need benefits? Do you need travel and lodging? I suggest searching the agencies current job availabilities to see if they are similar to your needs. For example, one agency may have an abundance of opportunities in your state, while another agency may have more job opportunities in your specialty.
  • Establish a relationship with your recruiter: You should have at least 5 agencies and recruiters that are actively searching for you. A good recruiter will be following up with you and returning your phone calls. It is common for locum tenens providers to bounce back and forth between agencies, depending on what jobs are available.
  • Get organized: Gather all of your licenses, certificates, CEU’s, vaccination records, and other documents you may need to submit. I recommend having them scanned to a computer so you can easily email them to your recruiters and credentialing team.
  • Have several references available: Most agencies and sites will ask for at least three references. Optimally one reference will be a supervisor or physician, and the other two references should be co-workers (other nurse practitioners or physician assistants). You should always have more than three references available, in case the agency cannot reach someone, to keep the process moving along.

Leaving Washington

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My last day at the community health center in Washington was bittersweet. Part of me was looking forward to going back home to the sunshine state from freezing temperatures (28-32 degrees). The other part of me was a little sad to leave because of all of the connections I had made with my co-workers and patients. The adventurous side of me see’s locum tenens opportunities as an exciting escapade. The sensitive side of me sees my sites as the people and relations I form, and reluctance to leave them behind.

The community health center asked me if there was anyway I would go permanent. I think most locum tenens sites that are looking for an ongoing commitment are hoping for a locums to permanent provider. My last day was a light load of seeing patients, with the later half of the day completing documentation. During lunchtime, most of the staff and I went to eat at a local pizza joint. Apparently I had the largest turn out of co-worker attendance :).

My supervisor at the clinic told me that all of the executives are sad to see me go. That they were impressed by my documentation and coding, and that I could teach the billing department a thing or two. They said they received an abundance of patient feedback that was positive about their experience with me, and requests for me to become their primary care provider. They also said that I transitioned really well into the clinic and they were happy to never have had an issue with me or my patient care. The medical director told me that he would be more than happy to be used as a reference or can provide a recommendation letter for future locum tenens positions.

I am truly grateful for my experience at the community health center. Not only did I learn a lot and fine-tune my skills and knowledge, but I also made some life long friends. I would not hesitate to return in the future (of course summer only) to help out with vacation shortages and other needed coverage. Saying good-bye was tough, but I know change is inevitable and can only strengthen a person. It will be difficult finding an upcoming locums opportunity that will match my experience in Washington.

Visiting Portland, Oregon

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Portland, Oregon is only a few hours drive from where I was in Washington. I decided to meet up with some friends in Portland one weekend. It was pretty much everything I expected it to be – interesting, hippie, and weird. I would definitely rather live in Seattle any day over Portland, but it was still a fun experience.

Right off the highway, we got to see the Multnomah Falls. It was a beautiful site with yellow and orange fall colored leaves surrounding it. As we got closer, mists from the falls quickly started covering us. We hiked up a bit to the bridge which brought us closer to the sounds of greatness.

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I have to admit that my favorite part of Portland were the “Powell Book Stores”. It’s incredible how vast a book store can be, with several editions of all types of books, both used and new. It is pretty much a nice book exchange program, where you can sell your lightly used books, and easily purchase other used or new books. There is a book I have been eyeing at Barnes and Nobles that costs almost $20. I bought it at Powell’s Book Store for less than $5. I wish I could have taken this book store with me back home.

We stopped over to the Portland Art Museum which I truly enjoyed. They have a good variety of cultural art such as Native American, Asian, European, and American works. My favorite item was a large Native American canoe that had multiple little canoes in it.

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Food-wise, we lucked out one morning at Voodoo Donuts. We only had to wait in line for 10 minutes compared to the usual 1 hour or so wait. I tried two different donuts that were good, especially the oreo/cookies and cream one. We bought a dozen donuts in between the 3 of us because it seemed like the right thing to do. Yet, we didn’t even finish half of it.

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Overall, I had such a fun weekend! Would I drive through those curvy roads at night on my way to Portland ever again? Probably not. Oregon is a great option for nurse practitioners looking to begin locum tenens work. There is always a need in Oregon and it’s a  pretty cool place.