The Complete Locum Tenens Guide: How Assignments, Agencies, Credentialing, and Pay Actually Work

Locum tenens ("to hold the place") is temporary clinical coverage: a facility needs a provider for a stretch of time, and you fill the gap as an independent contractor rather than an employee. This is not a "should I do locums" pep talk — it's a field manual for how the machinery actually runs, so you can walk into your first assignment knowing who does what, what you're signing, and how you get paid.

How the locum model works end to end

The core relationship is a triangle: you, the staffing agency, and the client facility. The facility pays the agency; the agency pays you as a contractor. You almost never sign an employment agreement with the hospital — your contract is with the agency.

The lifecycle looks like this:

1. Match. A recruiter presents you an assignment: specialty, location, dates, shift type, and estimated hours.
2. Presentation. With your permission, the agency submits your CV to the facility. This is a formal step — more on why it matters below.
3. Interview. Usually a short phone call with the medical director or scheduler.
4. Confirmation and credentialing. Once both sides agree, the agency opens credentialing and licensing workstreams in parallel. This is the long pole — plan for weeks, sometimes months for a new state license.
5. Logistics. Travel and housing get booked, typically by the agency.
6. Onboarding and the assignment itself. You work the block, submit time, and get paid.
7. Extend or roll off. Many assignments extend; a good one becomes recurring coverage.

Choosing agencies — and working with more than one

There is no rule against registering with several agencies, and experienced locums usually do. Different agencies hold different client relationships, so more agencies means more inventory. A practical starting filter: look for membership in NALTO, the National Association of Locum Tenens Organizations, whose members agree to a code of ethics covering honest job representation and conduct between agencies.

The one hard rule when working with multiple agencies: never let two agencies present you to the same facility. Duplicate submissions create a "who represents this candidate" dispute, can disqualify you from the job, and can get you a reputation you don't want. Keep your own log of exactly which agency submitted you to which facility and on what date, and require agencies to get your explicit sign-off before every single presentation.

Evaluate recruiters on responsiveness, transparency on pay, and whether they'll put commitments in writing. A recruiter who dodges the bill rate or won't confirm details in email is telling you something.

Contract essentials

Read the agency contract line by line before signing. Non-negotiable things to pin down:

• Rate and unit. Hourly or daily, and exactly which hours count.
• Call and overtime. Is call paid, at what rate, and what happens if you're called in?
• Schedule and minimum hours. Guaranteed hours or a stipend if the facility cancels shifts.
• Cancellation clause. How much notice must the facility give before your start date, and are you compensated if they cancel late? This protects you when you've already turned down other work.
• Travel and housing. Who books it, what's covered, and what happens if the assignment ends early.
• Malpractice coverage. The type of policy and who pays for tail coverage if applicable (see below).
• Restrictive covenants. Agencies commonly bar you from working at that facility directly or through another agency for a set period. Know the scope before you sign.
• Termination. Notice period for both sides.

Get every promise in the written contract. A verbal rate from a recruiter is not a rate.

Who handles what

Credentialing. The agency's credentialing team drives this, but the raw material is yours. Keep a current, complete CAQH profile and a correct NPPES/NPI record — accurate, attested, and updated. Have your work history with no unexplained gaps, references, immunization records, and current DEA registration ready. Facilities credentialed by The Joint Commission have strict primary-source verification requirements, which is the single biggest reason lead times run long.

Licensing. You must hold a license in the state where you practice. Physicians should look at the Interstate Medical Licensure Compact, which offers an expedited pathway for eligible MDs/DOs; the Federation of State Medical Boards is a useful reference on state boards. NPs and PAs should check whether their state participates in the APRN or PA Licensure Compact, which can streamline multistate practice. Agencies often reimburse or front new license fees for an assignment — confirm that in writing.

Travel and housing. Standard on most assignments: the agency books and pays for flights or mileage, a rental car, and lodging. Clarify whether housing is provided directly or reimbursed, and what standard.

Malpractice. Agencies typically provide professional liability coverage as part of the deal. The gold standard is occurrence-based coverage, which protects you for incidents that happened during the policy period no matter when a claim is filed — meaning you don't need to buy separate "tail" coverage later. Many agencies provide occurrence-based policies; verify which type you're getting and, if it's claims-made, who pays for tail. Ask for the policy limits and a certificate of insurance.

How pay actually works

Locums are paid as 1099 independent contractors, not W-2 employees. That has real consequences:

• No withholding. Taxes aren't taken out. You're responsible for your own income and self-employment tax, generally paid via quarterly estimated payments to the IRS. Set money aside from day one.
• No employer benefits. No employer health insurance, retirement match, or paid time off. Contractor status can open self-employed retirement options — talk to a tax professional.
• Business deductions. Legitimate, documented business expenses may be deductible. Keep clean records.

Typical structure: an hourly or daily rate for clinical time, often with separate call/overtime rates, plus travel and housing provided or reimbursed on top. Rates vary widely by specialty, location, shift type, and urgency, so compare total value — rate plus what's covered — not just the headline number.

Your first assignment, week by week

• Weeks 1–3 (pre-start): Sign the contract, complete credentialing packets, submit documents, and let the agency work the facility's medical staff office. Respond to document requests within hours, not days — you are the bottleneck if you stall.
• ~1 week out: Confirm travel, housing, start date, first-day contact, parking, badge, and EMR access. Ask for the shift schedule in writing.
• Day 1: Facility orientation, EMR login, and a walkthrough. Find your on-site contact and the on-call structure.
• First week working: Learn local workflows and who to call for what. Track your hours daily against the contract.
• End of each pay period: Submit and verify your timesheet promptly — pay depends on it. Flag any hours discrepancy immediately.

Red flags

• Pressure to start before credentialing and licensing are complete.
• A recruiter who won't put the rate, hours, or cancellation terms in writing.
• No clear answer on malpractice type and limits.
• Vague or missing cancellation/guarantee protection.
• Pushing you toward a facility another agency already submitted you to.
• Sloppy or absent contract language on travel, housing, and termination.

Treat locums like running a small business: verify everything in writing, keep your credentialing file perpetually current, and reserve for taxes. Do that and the model works cleanly in your favor.

References

• NALTO — National Association of Locum Tenens Organizations
• CAQH
• NPPES / NPI Registry (CMS)
• Interstate Medical Licensure Compact
• Federation of State Medical Boards
• The Joint Commission
• Drug Enforcement Administration (DEA)
• Internal Revenue Service (IRS)