H-1B Visa Clinical Manager Jobs
Clinical Manager roles qualify for H-1B visa sponsorship as specialty occupations requiring at least a bachelor's degree in nursing, healthcare administration, or a related field. Many hospital systems, outpatient networks, and long-term care operators sponsor H-1B petitions for this role, covering both cap-subject and cap-exempt filings depending on the employer type.
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Get Access To All JobsAbout this role: As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical operations. As the facility leader, you will be part of a close-knit, collaborative team responsible for delivering unique care plans and providing dialysis treatment to patients facing end stage renal disease or chronic kidney disease.
Training and advancement: You will enter our Clinical Leadership Program that creates and supports a culture of continuous learning for our managers. The curriculum will cover onboarding, essential functions, leading your business, and advanced leadership. As a Clinical Manager, you may advance your career into an Area Team Lead or Director of Operations role.
Our culture: We believe our employees are our most important asset — we value, care about, and support our people. We are there when you may need us most, from tuition reimbursement to support your education goals, granting scholarships to family members, delivering relief when natural disasters strike, or providing financial support when personal hardship hits, we take care of our people.
Our focus on diversity: We have built a nurturing environment that welcomes every age, race, gender, sexual orientation, background, and cultural tradition. We have a diverse range of employee resource groups (ERGs) to encourage employees with similar interests, goals, social and cultural backgrounds, or experiences to come together for professional and personal development, discussion, activities, and peer support. Our diverse workforce and culture encourage opportunity, equity, and inclusion for all, which is a tremendous asset that sets us apart.
At Fresenius Medical Care, you will truly make a difference in the lives of people living with kidney disease. If this sounds like the career and company you have been looking for, and you want to be a vital part of the future of healthcare, apply today.
PURPOSE AND SCOPE:
Manage and oversee the daily operations of the facility, ensuring cost-effective facility operations in accordance with all legal, compliance and regulatory requirements and programs. Collaborates with the Medical Director and the Clinical Manager/Charge Nurse regarding the provision of quality patient care in the dialysis facility incorporating all activities from admission through to discharge. As the clinic leader, has the authority to make daily decisions to ensure the appropriate continuity of care and patient and staff safety. Markets available services through presentations to physicians and dialysis facilities.
You will ensure that quality patient care is delivered while maintaining clinical operations. As the facility leader, you will be part of a close-knit, collaborative team responsible for delivering unique care plans and providing dialysis treatment to patients facing end stage renal disease or chronic kidney disease.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Clinic Operations:
- Provides leadership, coaching, and development plans for all direct reports.
- Partners with internal Human Resources, Quality, Education, and Technical Services departments.
- Collaborates with the Home Therapies Program Manager to oversee the facility’s Home Therapies Program.
- Maintains integrity of medical and operations records and complies with all data collections and auditing activities.
- Accountable for completion of the Internal Classification of Disease (ICD) coding.
- Responsible for all required network reporting and on-site state or federal surveys.
- Manages the tactical execution of short- and long-term objectives through the coordination of activities with a direct responsibility for results, including costs, methods, and staffing.
- Responsible for the administration of the daily business operations of the dialysis clinics including managing the functions and actions related to the center staff, quality of overall provision of patient care, maintenance of the physical plant and center equipment, and inventory control.
- Manages the profit and loss and other related financial aspects for the center, ensuring optimal facility operations to achieve or exceed the budget and key performance indicators.
Patient Care:
- Coordinates all aspects of patient care with the appropriate staff members, from admission through discharge of the patient.
- Acts as a resource for the patient and family to address concerns and questions.
- Oversee the timely completion of patient care assessments and care plans.
- Manages timely patient schedules to ensure facility efficiency and develop action plans for missed treatments.
- Reports changes in patient status regarding any clinical, insurance, or travel and transportation issues.
Staff:
- Participates in the selection and hiring of new team members and ensures completion of new hiring orientation and mandatory training.
- Responsible for all patient care employees completing appropriate training courses and that licensures/certifications are current.
- Provides support for all clinical staff members at regular intervals and encourages professional growth.
- Maintains current knowledge regarding company benefits, policies, procedures, and processes.
- Obtains clinical feedback for employee evaluations and establishes annual goals and conducts employee evaluations.
- Documents any disciplinary actions and confers with the clinic Director of Operations and Human Resources when needed.
- Manages staff scheduling and payroll.
Physicians:
- Facilitates the application process for physician privileges and compliance with Fresenius Medical Care Medical Staff By-Laws.
- Responsible for strong physician relationships and ensures regular and effective communication.
- Participates in Governing Body, an interdisciplinary team for each region including MDs, DOs etc. that governs policies.
Other:
- Collaborates closely with, providing oversight as needed to, the Clinical Manager/Charge RN acting as nurse manager, the Medical Director, and the physicians regarding the direct patient care responsibilities within the facility to ensure the provision of outstanding quality of patient care, as defined by the FMS quality goals, and compliance with the pertinent company policies and procedures. Collaboration activities include:
- Coordinating all aspects of patient care from admission through discharge of the patient.
- Addressing patient concerns, issues, and questions including the review of patient satisfaction surveys.
- Developing and communicating efficient and timely patient schedules to ensure maximization of facility efficiency.
- Assisting as needed with patient workflow.
- Implementing and maintaining a Continuous Quality Improvement (CQI) Process and Quality Assessment and Improvement Program (QAPI) Improvement Team that involves staff and pertinent physicians in problem solving activities meeting on a regular basis to address identified issues.
- Continually review Center operations to ensure compliance with Federal and State laws.
- Develops and maintains strong Medical Director and physician relationships, facilitating staff relationships with physicians, and ensuring regular and effective communication with all physicians including participating in regular meetings with Medical Directors.
- Supports and drives FMS quality standards through meeting regulatory requirements and the practice of CQI, including the use of the appropriate company CQI tools.
- Works with the Charge RN and Medical Director to implement FMS quality FKC goals and develop facility specific action plans to achieve FMS quality standards.
- Oversees and monitors the provision of the appropriate training according to FMS policy to ensure ongoing compliance with all company and FMS risk management initiatives.
- Collaborates with the Charge RN to ensure the aggressive treatment of, and actions taken, regarding adverse safety events and action thresholds.
- Ensures all Quality policies and procedures are communicated to and implemented by the facility staff.
- Maintains integrity of medical records and other FMS administrative and operational records.
- Complies and assists with all data collection and auditing activities.
- Manages the day-to-day activities and workload of the facility staff providing guidance and leadership as appropriate to ensure the effective, efficient and timely execution of duties and tasks.
- Creates, maintains, and communicates efficient and timely employee schedules according to the staffing needs of the facility to ensure adequate staffing daily. Consults with Charge RN and Medical Director to optimize clinical staffing.
- Provides informal feedback to staff on an ongoing basis and formal feedback in the form of the annual performance evaluation during the focal merit review process. Obtains feedback and input regarding the staff performance from the Medical Director and Charge RN and acts on the feedback as appropriate. Collaborates with staff and Charge RN and Medical Director to set annual goals for staff.
- Manages the department staffing through the appropriate hiring, firing and disciplinary actions.
- Maintains written documentation of all disciplinary meetings in accordance with the established personnel policies and confers with Human Resources and Director of Operations regarding the nature of the disciplinary decisions.
- Ensures successful execution of new hire orientation and training, and ICD-9 code training when ICD-10 applicable for new hires and works with Medical Director to ensure mandatory in-services are completed.
- Ensures appropriate documentation is completed for current licensure, annual in-service and policy and procedure in-service updates.
- Responsible for ensuring all facility employees receive appropriate training according to company policy including company risk management initiatives.
- Provides training and guidance to facility staff members to ensure development of clinical competences, providing opportunities for professional growth and encouraging personal growth.
- Collaborates with HR regarding providing information to staff pertaining to FMS/FMCNA benefits, Human Resources policies and procedures.
- Participates in Corporate and Division specific employee recognition and satisfaction programs.
- Maintains a close working relationship with Division and Corporate office personnel and ensures appropriate communication of FMS, Division, and Corporate initiatives, policies and procedures to facility staff.
- Utilizes knowledge of FMCNA and FMS services and products to contribute to the growth of the business.
- Maintains facility environmental integrity and safety.
- Schedules the maintenance and repair of equipment, operating systems, and physical structure of the facility, as needed.
- Monitors the security of the facility.
- Coordinates inventory/supply management by reviewing monthly inventory count and approving purchase orders for necessary items to ensure cost containment, timely distribution and competitive pricing.
- Responsible for efficient utilization of medication, laboratory, inventory, supplies and equipment to achieve supply cost goals following all guidelines established in the FMS/FMS formularies.
- Contributes to the development and revision of any applicable policies and procedures for the facility and the pertinent updating and maintenance of the related manuals.
- Directs any necessary information gathering, as required, to support billing, billing issues and collection activities.
- Coordinates and approves facility payroll.
- Responsible for participating in all on-site internal and external (state and federal) surveys.
- Reviews new and existing provider contracts for various vendor services, including but not limited to, insurance, laboratory, and facility cleaning.
- Performs other related duties as assigned.
SUPERVISION:
Supervises Charge RN and DPC Staff
PHYSICAL DEMANDS AND WORKING CONDITIONS:
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Day to day work includes desk and personal computer work and interaction with patients, facility staff and physicians.
- The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials.
- The position requires frequent prolonged periods of standing and the employee must be able to bend over.
- The employee may occasionally be required with assistance to move patients and equipment of up to 200 lbs. There is a two-person assist program and “material assist” devices for the heavier items.
- Travel to regional, Business Unit and Corporate meetings may be required.
Education:
- Graduate of an accredited School of Nursing (RN)
- Current RN state licensure
EXPERIENCE AND REQUIRED SKILLS:
- Experience in clinical nursing.
- Additional 6 months chronic or acute dialysis nursing experience.
- Demonstrated leadership competencies and management skills for the position, including excellent communication, customer service, continuous quality improvement, relationship development, results orientation, team building, motivating employees, performance management and decision making.
- Demonstrated management skills necessary to provide leadership in the supervision of facility personnel and to ensure the delivery of maximum quality care to all patients.
- Successfully passed the Ishihara Color Blind Test.
Preferred:
- Experience in a supervisory/management role, in a medical facility preferred.
- Med/surg or ICU/CCU experience preferred.
- Proficiency with the Microsoft office suite (Word, Excel, PowerPoint) - experience with medical database software preferred.
EOE, disability/veterans
About this role: As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical operations. As the facility leader, you will be part of a close-knit, collaborative team responsible for delivering unique care plans and providing dialysis treatment to patients facing end stage renal disease or chronic kidney disease.
Training and advancement: You will enter our Clinical Leadership Program that creates and supports a culture of continuous learning for our managers. The curriculum will cover onboarding, essential functions, leading your business, and advanced leadership. As a Clinical Manager, you may advance your career into an Area Team Lead or Director of Operations role.
Our culture: We believe our employees are our most important asset — we value, care about, and support our people. We are there when you may need us most, from tuition reimbursement to support your education goals, granting scholarships to family members, delivering relief when natural disasters strike, or providing financial support when personal hardship hits, we take care of our people.
Our focus on diversity: We have built a nurturing environment that welcomes every age, race, gender, sexual orientation, background, and cultural tradition. We have a diverse range of employee resource groups (ERGs) to encourage employees with similar interests, goals, social and cultural backgrounds, or experiences to come together for professional and personal development, discussion, activities, and peer support. Our diverse workforce and culture encourage opportunity, equity, and inclusion for all, which is a tremendous asset that sets us apart.
At Fresenius Medical Care, you will truly make a difference in the lives of people living with kidney disease. If this sounds like the career and company you have been looking for, and you want to be a vital part of the future of healthcare, apply today.
PURPOSE AND SCOPE:
Manage and oversee the daily operations of the facility, ensuring cost-effective facility operations in accordance with all legal, compliance and regulatory requirements and programs. Collaborates with the Medical Director and the Clinical Manager/Charge Nurse regarding the provision of quality patient care in the dialysis facility incorporating all activities from admission through to discharge. As the clinic leader, has the authority to make daily decisions to ensure the appropriate continuity of care and patient and staff safety. Markets available services through presentations to physicians and dialysis facilities.
You will ensure that quality patient care is delivered while maintaining clinical operations. As the facility leader, you will be part of a close-knit, collaborative team responsible for delivering unique care plans and providing dialysis treatment to patients facing end stage renal disease or chronic kidney disease.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Clinic Operations:
- Provides leadership, coaching, and development plans for all direct reports.
- Partners with internal Human Resources, Quality, Education, and Technical Services departments.
- Collaborates with the Home Therapies Program Manager to oversee the facility’s Home Therapies Program.
- Maintains integrity of medical and operations records and complies with all data collections and auditing activities.
- Accountable for completion of the Internal Classification of Disease (ICD) coding.
- Responsible for all required network reporting and on-site state or federal surveys.
- Manages the tactical execution of short- and long-term objectives through the coordination of activities with a direct responsibility for results, including costs, methods, and staffing.
- Responsible for the administration of the daily business operations of the dialysis clinics including managing the functions and actions related to the center staff, quality of overall provision of patient care, maintenance of the physical plant and center equipment, and inventory control.
- Manages the profit and loss and other related financial aspects for the center, ensuring optimal facility operations to achieve or exceed the budget and key performance indicators.
Patient Care:
- Coordinates all aspects of patient care with the appropriate staff members, from admission through discharge of the patient.
- Acts as a resource for the patient and family to address concerns and questions.
- Oversee the timely completion of patient care assessments and care plans.
- Manages timely patient schedules to ensure facility efficiency and develop action plans for missed treatments.
- Reports changes in patient status regarding any clinical, insurance, or travel and transportation issues.
Staff:
- Participates in the selection and hiring of new team members and ensures completion of new hiring orientation and mandatory training.
- Responsible for all patient care employees completing appropriate training courses and that licensures/certifications are current.
- Provides support for all clinical staff members at regular intervals and encourages professional growth.
- Maintains current knowledge regarding company benefits, policies, procedures, and processes.
- Obtains clinical feedback for employee evaluations and establishes annual goals and conducts employee evaluations.
- Documents any disciplinary actions and confers with the clinic Director of Operations and Human Resources when needed.
- Manages staff scheduling and payroll.
Physicians:
- Facilitates the application process for physician privileges and compliance with Fresenius Medical Care Medical Staff By-Laws.
- Responsible for strong physician relationships and ensures regular and effective communication.
- Participates in Governing Body, an interdisciplinary team for each region including MDs, DOs etc. that governs policies.
Other:
- Collaborates closely with, providing oversight as needed to, the Clinical Manager/Charge RN acting as nurse manager, the Medical Director, and the physicians regarding the direct patient care responsibilities within the facility to ensure the provision of outstanding quality of patient care, as defined by the FMS quality goals, and compliance with the pertinent company policies and procedures. Collaboration activities include:
- Coordinating all aspects of patient care from admission through discharge of the patient.
- Addressing patient concerns, issues, and questions including the review of patient satisfaction surveys.
- Developing and communicating efficient and timely patient schedules to ensure maximization of facility efficiency.
- Assisting as needed with patient workflow.
- Implementing and maintaining a Continuous Quality Improvement (CQI) Process and Quality Assessment and Improvement Program (QAPI) Improvement Team that involves staff and pertinent physicians in problem solving activities meeting on a regular basis to address identified issues.
- Continually review Center operations to ensure compliance with Federal and State laws.
- Develops and maintains strong Medical Director and physician relationships, facilitating staff relationships with physicians, and ensuring regular and effective communication with all physicians including participating in regular meetings with Medical Directors.
- Supports and drives FMS quality standards through meeting regulatory requirements and the practice of CQI, including the use of the appropriate company CQI tools.
- Works with the Charge RN and Medical Director to implement FMS quality FKC goals and develop facility specific action plans to achieve FMS quality standards.
- Oversees and monitors the provision of the appropriate training according to FMS policy to ensure ongoing compliance with all company and FMS risk management initiatives.
- Collaborates with the Charge RN to ensure the aggressive treatment of, and actions taken, regarding adverse safety events and action thresholds.
- Ensures all Quality policies and procedures are communicated to and implemented by the facility staff.
- Maintains integrity of medical records and other FMS administrative and operational records.
- Complies and assists with all data collection and auditing activities.
- Manages the day-to-day activities and workload of the facility staff providing guidance and leadership as appropriate to ensure the effective, efficient and timely execution of duties and tasks.
- Creates, maintains, and communicates efficient and timely employee schedules according to the staffing needs of the facility to ensure adequate staffing daily. Consults with Charge RN and Medical Director to optimize clinical staffing.
- Provides informal feedback to staff on an ongoing basis and formal feedback in the form of the annual performance evaluation during the focal merit review process. Obtains feedback and input regarding the staff performance from the Medical Director and Charge RN and acts on the feedback as appropriate. Collaborates with staff and Charge RN and Medical Director to set annual goals for staff.
- Manages the department staffing through the appropriate hiring, firing and disciplinary actions.
- Maintains written documentation of all disciplinary meetings in accordance with the established personnel policies and confers with Human Resources and Director of Operations regarding the nature of the disciplinary decisions.
- Ensures successful execution of new hire orientation and training, and ICD-9 code training when ICD-10 applicable for new hires and works with Medical Director to ensure mandatory in-services are completed.
- Ensures appropriate documentation is completed for current licensure, annual in-service and policy and procedure in-service updates.
- Responsible for ensuring all facility employees receive appropriate training according to company policy including company risk management initiatives.
- Provides training and guidance to facility staff members to ensure development of clinical competences, providing opportunities for professional growth and encouraging personal growth.
- Collaborates with HR regarding providing information to staff pertaining to FMS/FMCNA benefits, Human Resources policies and procedures.
- Participates in Corporate and Division specific employee recognition and satisfaction programs.
- Maintains a close working relationship with Division and Corporate office personnel and ensures appropriate communication of FMS, Division, and Corporate initiatives, policies and procedures to facility staff.
- Utilizes knowledge of FMCNA and FMS services and products to contribute to the growth of the business.
- Maintains facility environmental integrity and safety.
- Schedules the maintenance and repair of equipment, operating systems, and physical structure of the facility, as needed.
- Monitors the security of the facility.
- Coordinates inventory/supply management by reviewing monthly inventory count and approving purchase orders for necessary items to ensure cost containment, timely distribution and competitive pricing.
- Responsible for efficient utilization of medication, laboratory, inventory, supplies and equipment to achieve supply cost goals following all guidelines established in the FMS/FMS formularies.
- Contributes to the development and revision of any applicable policies and procedures for the facility and the pertinent updating and maintenance of the related manuals.
- Directs any necessary information gathering, as required, to support billing, billing issues and collection activities.
- Coordinates and approves facility payroll.
- Responsible for participating in all on-site internal and external (state and federal) surveys.
- Reviews new and existing provider contracts for various vendor services, including but not limited to, insurance, laboratory, and facility cleaning.
- Performs other related duties as assigned.
SUPERVISION:
Supervises Charge RN and DPC Staff
PHYSICAL DEMANDS AND WORKING CONDITIONS:
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Day to day work includes desk and personal computer work and interaction with patients, facility staff and physicians.
- The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials.
- The position requires frequent prolonged periods of standing and the employee must be able to bend over.
- The employee may occasionally be required with assistance to move patients and equipment of up to 200 lbs. There is a two-person assist program and “material assist” devices for the heavier items.
- Travel to regional, Business Unit and Corporate meetings may be required.
Education:
- Graduate of an accredited School of Nursing (RN)
- Current RN state licensure
EXPERIENCE AND REQUIRED SKILLS:
- Experience in clinical nursing.
- Additional 6 months chronic or acute dialysis nursing experience.
- Demonstrated leadership competencies and management skills for the position, including excellent communication, customer service, continuous quality improvement, relationship development, results orientation, team building, motivating employees, performance management and decision making.
- Demonstrated management skills necessary to provide leadership in the supervision of facility personnel and to ensure the delivery of maximum quality care to all patients.
- Successfully passed the Ishihara Color Blind Test.
Preferred:
- Experience in a supervisory/management role, in a medical facility preferred.
- Med/surg or ICU/CCU experience preferred.
- Proficiency with the Microsoft office suite (Word, Excel, PowerPoint) - experience with medical database software preferred.
EOE, disability/veterans
See all 1,378+ H-1B Visa Clinical Manager Jobs
Sign up for free to unlock all listings, filter by visa type, and get alerts for new H-1B Visa Clinical Manager Jobs.
Get Access To All JobsTips for Finding H-1B Visa Sponsorship as a Clinical Manager
Verify your credentials meet specialty occupation standards
USCIS evaluates Clinical Manager petitions against the specialty occupation definition. A clinical or administrative degree tied directly to the role strengthens your case. If your degree is in a adjacent field, gather employer letters explaining why the specific degree is standard for the position.
Target cap-exempt employers first
Hospitals affiliated with universities and nonprofit research institutions can file H-1B petitions year-round without entering the lottery. Clinical Manager openings at academic medical centers give you a faster path to status than standard cap-subject filings.
Search LCA filing history before applying
Use Migrate Mate to filter Clinical Manager openings by employers with verified DOL Labor Condition Application filings for this occupation code. That filing history confirms the employer has sponsored this exact role before, not just adjacent titles.
Confirm the prevailing wage tier before negotiating
Look up the Clinical Manager SOC code in the OFLC Wage Search for the metro area where the role is based. Your offered salary must meet at least the Level I prevailing wage. Knowing the tiers before your offer conversation prevents surprises after the LCA is filed.
Ask about the H-1B filing timeline during interviews
Cap-subject petitions must be filed by April 1 for an October 1 start. If you're interviewing in late winter, confirm your prospective employer can complete the LCA certification and I-129 preparation within that window. Delays in credentialing verification are the most common bottleneck for clinical roles.
Prepare a credentials package before the offer stage
Foreign nursing or healthcare management credentials often require evaluation before USCIS will accept them as equivalent to a U.S. degree. Have a NACES-member credential evaluation completed and your transcripts translated before your employer begins the I-129 petition to avoid delaying your start date.
H-1B Visa Clinical Manager: Frequently Asked Questions
Does a Clinical Manager role qualify as a specialty occupation for H-1B purposes?
Yes, provided the position requires at least a bachelor's degree in a specific field such as nursing, healthcare administration, or health services management. The employer must document in the LCA and I-129 that the role normally requires a degree in a directly related discipline, not that any bachelor's degree will suffice. Roles where a general management degree substitutes freely are more vulnerable to USCIS requests for evidence.
Which types of employers sponsor H-1B visas for Clinical Manager jobs?
Hospital systems, multi-site outpatient groups, long-term care networks, and managed care organizations are the most active sponsors. Nonprofit hospitals affiliated with universities can file as cap-exempt employers, bypassing the annual lottery. For-profit health systems file as cap-subject employers and must compete in the April registration. Use Migrate Mate to browse Clinical Manager openings filtered by employers with confirmed H-1B filing history.
How does the H-1B lottery affect my timeline as a Clinical Manager candidate?
Cap-subject petitions are registered in March, with selections announced shortly after. If selected, your employer files the full I-129 by April 1, and employment begins no earlier than October 1. This means a January job offer at a for-profit employer may not translate to an authorized start date for nine months. Cap-exempt employers at qualifying nonprofits or universities can file and begin employment on approval, with no October 1 restriction.
Can a Clinical Manager change employers while on H-1B status?
Yes. Under H-1B portability rules, you can start working for a new employer as soon as the new I-129 petition is filed, not when it's approved, as long as you've been in valid H-1B status for at least 180 days. Your new employer must file a transfer petition with a new LCA certified for the new worksite location and wage. Confirm the new position still meets specialty occupation criteria under the new employer's job description.
What documentation should I expect my employer to request for the H-1B filing?
Your employer's attorney will typically need your educational transcripts, credential evaluation if your degree is from outside the U.S., a copy of any professional licenses relevant to your state, and a detailed description of your Clinical Manager duties. If your foreign credentials haven't been evaluated, a NACES-member evaluation is usually required. Starting this paperwork before the offer is finalized prevents delays at the LCA and I-129 preparation stages.