Many recent studies have looked at the labor market effects of immigrants on native workers using cross-sectional survey data, yielding inconclusive results and shedding little light on the firm-level and industry-level processes which lead to observed outcomes. Towards an understanding of these processes, this paper examines the skill requirements and hiring procedures for entry-level jobs in the hospital industry, utilizing interviews with managers in Los Angeles County hospitals. The substitutability of immigrant for native labor is affected by a number of factors. Job complexity and English language requirements, for instance, favor African Americans, who have long been over-represented in area hospitals, over less-skilled immigrants. Upskilling in many jobs, however, increasingly excludes less-educated natives and immigrants alike, while privatization of some functions has led to the rise of low-wage contracting firms which minimize both skills and wages and employ mainly immigrants.