Do You Need a COO? How Practice Leaders Know When to Bring In Non-Clinical Leadership

Does Your Practice Need a COO?

If you’re the founder or clinical director of a growing behavioral health group practice, chances are your week looks something like this: supervising clinical staff, reviewing a tricky treatment plan, approving payroll, fielding a billing question, and somewhere in there, trying to see clients yourself. Every decision, big or small, ends up on your desk.

That’s normal in year one. By year five, with 20 or more staff and a real Medicaid caseload, it’s usually a sign you’ve outgrown the way the organization is being run — not a sign you need to work harder.

Why this happens to almost every growing practice

Clinical training prepares you to run a caseload. It doesn’t prepare you to run a business. Most founders learn billing, HR, compliance infrastructure, and operations on the fly, squeezed in around actual clinical work, because there was never anyone else to hand it to.

That arrangement holds up fine at a small scale. It breaks down as you add staff, add payer contracts, and add the kind of regulatory complexity that comes with Medicaid billing and CARF accreditation. And it’s an especially expensive way to run things given how scarce clinical leadership actually is: HRSA’s most recent workforce projections show demand for behavioral health services growing roughly four times faster than the supply of providers through the early 2030s. Every hour your clinical director spends on scheduling software or an invoice dispute is an hour of increasingly scarce clinical expertise not being used for clinical work.

Signs it’s time to bring in operational leadership

There’s no single headcount number that triggers this. It’s more about where the friction shows up. A few signals we see consistently in Medicaid-focused agencies:

  • Decisions — hiring, vendor contracts, scheduling changes — stack up waiting on one person, and things slow down noticeably when that person is out.
  • Growth has plateaued even though referral demand hasn’t, usually because there’s no one dedicated to solving the operational bottlenecks standing in the way.
  • The clinical director or founder is spending more hours on billing, HR, or administrative firefighting than on clinical supervision or care quality.
  • Financial or compliance blind spots are surfacing — the kind of gaps we’ve written about in the context of Medicaid audits and CARF surveys — because no one owns operational oversight full-time.

If two or three of these sound familiar, that’s usually enough signal to start the conversation, even if you’re not ready to hire immediately.

Practice 360 Health Assessment

What the role actually covers

Titles vary — Chief Operating Officer, VP of Operations, Practice Administrator — but the function is consistent: a non-clinical leader who owns the business side of the organization so your clinical leadership can stay focused on clinical leadership.

In practice, that usually means:

  • Revenue cycle oversight — billing, denials, payer relationships, and cash flow.
  • HR and staffing infrastructure, including hiring, onboarding, and retention systems.
  • Compliance and documentation systems that hold up under a CARF survey or Medicaid audit.
  • Operational planning — the unglamorous work of building workflows and reporting that let the organization run without depending on any one person’s memory.

SAMHSA’s behavioral health leadership resources point to the same conclusion the field has been converging on for years: organizational sustainability depends on developing leadership capacity that’s distinct from clinical expertise, not layered entirely on top of it.

Where agencies get this wrong

The most common mistake isn’t hiring too early — it’s hiring too late, after burnout has already set in or a compliance gap has already caused real damage. The second most common mistake is hiring a generic business executive with no behavioral health or Medicaid background, and then watching them struggle with the regulatory complexity that makes this sector different from a typical small business.

The fix for the first problem is simply paying attention to the signs above before they become a crisis. The fix for the second is being honest in the hiring process about how much of the job is Medicaid-specific — enrollment rules, payer mix management, documentation requirements — versus general operations experience that transfers from any industry.

It’s also worth deciding, before you hire, where clinical authority ends and operational authority begins. Ambiguity here is where a lot of new COO relationships go sideways, not because either person is doing a bad job, but because nobody defined who decides what.

Practice 360 Health Assessment

Building toward this, even before you’re ready to hire

If a full-time executive hire isn’t realistic yet, the same discipline still applies at a smaller scale: document your workflows, centralize your reporting, and get your revenue cycle and compliance systems running on structure rather than institutional memory. That work makes the eventual hire easier, and it makes the organization more resilient in the meantime, whether or not that hire happens on the timeline you expect.

This connects directly to something we touched on in our last post about mergers and acquisitions in behavioral health: whether you’re preparing to bring in outside leadership, considering a sale, or just trying to grow sustainably, the underlying need is the same — systems solid enough that the organization doesn’t depend entirely on one person holding it all together.

We’re hosting a live session specifically on placing non-clinical executives and operators into behavioral health group practices. Save your seat here — details on date and time are on the registration page.

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