PRN & Per-Diem Income.
PRN (pro re nata — "as needed") work is the most chronically mis-handled income in healthcare lending. The default underwriting position is that PRN income is too irregular to count. That's wrong.
PRN income qualifies under the same rules as part-time or secondary employment (Fannie B3-3.1-09): demonstrable two-year history, stable or increasing pattern, and reasonable continuance argument. For nurses with a steady PRN pattern at a single facility, the income often qualifies at 90-100% of the average. Multi-facility PRN requires more documentation but works. We've structured hundreds of PRN files — we know which lenders treat it correctly.
Travel Nurse Contracts.
Travel nursing is the highest-paying nursing arrangement in America — and the most complicated for underwriting. A traveler typically works 13-week assignments at multiple hospitals, often across multiple states, with W-2 income, tax-free stipend income, and per-diem allowances all mixed together.
The qualifying approach: document the contract history (last 24 months of assignments), separate W-2 wages from the tax-free stipend (which doesn't count for DTI), and demonstrate continuance of the traveler lifestyle through current contract + signed pending contracts. We work with the agency directly to gather employment verification when needed. Most retail lenders simply refuse traveler files — we close them.
Shift Differential & Holiday Pay.
Night differential (typically 10-15%), weekend differential (10-20%), holiday pay (1.5-2× base), and on-call pay all add meaningful income for nurses working non-standard schedules. The treatment: documented through payroll history, qualifying as variable income with 24-month averaging. For nurses on steady night shift, the differential is effectively base pay.
Resident & Fellow Income.
Medical residents and fellows present a unique underwriting picture: relatively low current salary ($60K-$70K typical), strong future earning potential, and an employment history that's heavy on education but light on years-at-current-job. The solution: physician loan programs.
Most major lenders offer physician loans (sometimes called "doctor loans") that:
- Allow up to 100% financing (no PMI) with strong credit
- Use the future employment contract as qualifying income (residents starting a $250K attending position can qualify on that figure 60-90 days before the start date)
- Exclude student loan debt from DTI in some configurations (or use income-driven repayment minimum)
We have direct relationships with the lenders running the most generous physician loan programs and place these files routinely.
Sign-On Bonuses.
Healthcare sign-on bonuses are common — often $10,000-$30,000 for nurses, more for specialized clinicians. Underwriting treatment: typically not counted as recurring income (it's one-time), but the offer letter and bonus amount help establish income stability. We don't pad files with sign-on bonus dollars that won't survive a re-pull.
1099 Healthcare Income (Locum Tenens & Independent Contractors).
Physicians working locum tenens, NPs and PAs in independent practice, and contracted nurses (less common but real) earn 1099 income that requires self-employment underwriting. Two years of tax returns are typically required; we can also structure these files as bank-statement loans through our Non-QM programs when traditional documentation comes up short.