Fractional CFO and COO for FQHCs: The Leadership Model Helping Health Centers Do More With Less

If you've ever lost a CFO or COO - or spent months trying to recruit one-you already know how costly and destabilizing that gap can be. The finances drift. Compliance risks mount. The leadership team makes decisions without the strategic financial guidance they need. And meanwhile, your job posting sits on Indeed collecting views but no viable candidates.

There's a model that addresses exactly this problem, and most health centers aren't using it.

In Episode 25 of the Community Health Collective Podcast, I sat down with Rebecca Mankin-a certified government financial manager (CGFM), ACHE fellow, and founder of Mankin Consulting, LLC-to talk about the fractional executive model and what it can actually do for a community health center. Rebecca has served as fractional CEO, COO, and CFO for multiple FQHCs simultaneously, and her firm has led financial audits for health centers with combined budgets exceeding $100 million.

Here's what I learned.

What Is a Fractional Executive?

A fractional executive is not a consultant. They don't come in, hand you a report, and leave. They're also not a traditional interim-someone holding a seat warm until the 'real' hire arrives.

A fractional executive is embedded in your organization. They're in your meetings. They're making decisions. They're accountable for outcomes. The difference is that they work a fraction of the time-typically 10 to 30 hours per week-and at a fraction of the cost of a full-time C-suite hire.

As Rebecca describes it: 'I step in as part of the leadership team, but without being a full-time hire. I lead, guide, stabilize, and build-not just advise from the outside.'

The engagement length is flexible. Some run a few months; others extend over a year or more depending on the organization's needs and transition timeline. A fractional leader like Rebecca might be supporting two to five organizations at once, depending on the hours committed to each.

Why FQHCs Need FQHC-Specific Expertise

One of the most important points Rebecca makes is this: not all fractional executives are equal. Hiring an accountant to handle your health center's finances is very different from hiring someone who understands the 330 grant, 340B compliance, UDS reporting, sliding fee scale requirements, cost reporting, and payer mix dynamics.

A generalist can keep the books. A fractional CFO with FQHC experience can help you write a budget for a new grant opportunity, identify where your revenue cycle is bleeding, and position you strategically for whatever comes next in the funding environment.

The ramp-up time is dramatically shorter-and the impact is dramatically deeper-when the person already knows your world.

The Financial Blind Spots Rebecca Finds Most Often

When Rebecca walks into a health center for the first time, here's what she's looking at: UDS reports, audits, 990s, and strategic plans. And here's what she consistently finds:

• No real-time financial visibility. Financials are being reported monthly (good), but there are no KPI dashboards-leaders are always looking in the rearview mirror instead of watching the road ahead.
• Revenue cycle inefficiencies. Most health centers don't have a billing dashboard that shows where in the cycle claims are getting stuck. They're not tracking denial reasons by root cause. Revenue is leaking in ways that nobody has quantified.
• Misalignment between operations and finance. As organizations grow and leadership transitions happen, the connection between the finance team and operations often breaks down. Decisions get made in silos. The dots don't get connected.
• Under- or over-utilization of data. Measuring 100 KPIs is as paralyzing as measuring none. Rebecca's advice: pick 10 that matter most right now and actually use them.

The Real Cost Comparison: Fractional vs. Full-Time

Here's where the conversation gets very practical. Health center boards and CEOs often push back on the fractional model with some version of: 'We need someone full-time. We can't share an executive.'

Rebecca's response: 'You don't always need more time. You need the right experience at the right time.'

When you add up the true cost of a full-time C-suite hire-salary, benefits, recruitment fees, relocation expenses, onboarding time, and the months before they're fully productive-it's a significant investment. And if you rush the hire because there's urgency to fill the seat, you may not end up with the most qualified person for the job.

A fractional executive lets you pay only for what you need, get immediate impact, avoid long hiring timelines, and take the time to find the right permanent hire-without the financial function going dark in the meantime.

The ROI Rebecca aims to demonstrate: identify revenue opportunities or savings that generate measurable new dollars-enough to pay for the fractional engagement many times over, and leave the organization with sustainable systems when she exits.

One real example she shared: a health center she worked with went from 6 days cash on hand to 80 days. Without laying off a single person.

How to Vet a Fractional Executive

This is where I want every health center leader to slow down and pay attention. The fractional model only works when you bring in the right person. And unfortunately, not everyone putting themselves out there as a fractional executive has the background to back it up.

Rebecca's guidance:

• Do real reference checks-the same way you would for a full-time hire. Ask about outcomes, not just tenure.
• Look at their LinkedIn recommendations. Do they reflect specific, outcome-based results? Or are they generic?
• Ask your state PCA for recommendations. They often know who's doing good work in the FQHC world.
• Check national associations for vetted vendors and contractors.
• Beware of the 'slice and dice' approach. A good fractional executive should offer a balanced strategy-looking at revenue enhancement, cost containment, contract negotiations, and operational improvement-not just headcount reduction as the default answer.
• Make sure they execute, not just advise. You want someone who rolls up their sleeves and gets in the work with you.

When Fractional Doesn't Work

The model isn't a fit for every situation. If a health center has virtually no financial infrastructure-a one or two-person shop with no established processes, no segregation of duties, no baseline structure-a fractional CFO may not be able to operate effectively. In that case, the first step is a foundational assessment to determine what structure is actually needed before considering a fractional arrangement.

The Current Environment: Why This Matters Now

Health centers right now are navigating funding uncertainty, workforce shortages, compliance demands, and new opportunities like the Rural Health Transformation Program-all at the same time. It's the conditions that most commonly trigger what Rebecca calls 'analysis paralysis': leaders go into lockdown mode, stop thinking strategically, and default to cutting.

Rebecca's framing for leaders in that space: 'What is it that you'd like to see accomplished in 30, 60, 90 days that I can help you with?' A fractional engagement doesn't have to be open-ended. It can be scoped, transparent, and results-focused-with clear deliverables and an honest assessment of whether it's working.

As I said on the episode: when you're inside the bottle, you can't read the label. Sometimes the most important thing a struggling health center can do is bring in someone who has seen this before, knows what works, and can get you moving in the right direction.

Is a Fractional Executive Right for Your Health Center?

Rebecca's quick self-assessment: if your organization is facing funding uncertainty, workforce challenges, or increased compliance demands-and you don't have the internal capacity or expertise to address them-it's worth a conversation about fractional leadership.

Connect with Rebecca Mankin

• Website: mankinconsultingservices.com
• Phone: (660) 223-6212
• LinkedIn: linkedin.com/in/rebecca-mankin-mpa-cgfm-ache-79980baa/

Connect with Jill Steeley

• Website: www.jillsteeley.com
• Email: [email protected]
• LinkedIn: www.linkedin.com/in/jillsteeley

► Listen to Episode 25 of the Community Health Collective Podcast