Fractional COO to an early-stage startup

The story

I started working with an early-stage telehealth platform in 2023. They'd just secured seed funding and built a working product connecting patients with physicians for virtual consultations. The founding team—two physicians and a software engineer—had strong clinical and technical skills but were drowning operationally.

When I came in, it was chaos. Patients were booking appointments, but providers weren't showing up. Insurance claims sat in piles, unprocessed, strangling cash flow. The fifteen-person team had no clear roles, and the founders were working 80-hour weeks doing everything from customer service to payroll. They were bringing in $180,000 monthly but burning through $50,000 each month. Without operational infrastructure, they couldn't grow - they were just treading water.

What I Did

They brought me in as a fractional COO at around $10,000 monthly - far less than the $200,000-plus a full-time executive would cost. I'd spent my entire career in strategy and operations, so I knew what to look for. I started with a diagnostic assessment to understand what was actually broken.

The problems were clear: no standardized workflows, inefficient scheduling systems, delayed billing processes, and nobody really knew who was responsible for what. I focused on five critical interventions.

First, I implemented an automated scheduling system that linked provider availability directly to patient booking. This cut out the double-bookings and empty appointment slots immediately. Provider utilization jumped 28 percent.

Second, I streamlined billing workflows. We started submitting insurance claims within 24 hours instead of letting them sit for weeks. Cash conversion cycles improved from forty-two days to twenty-five days, which freed up $65,000 in trapped receivables.

Third, I documented everything - patient onboarding, provider credentialing, complaint handling—so operations didn't depend on whoever remembered how things worked. Everyone finally knew their role.

Fourth, I right-sized the team structure. Three overlapping administrative roles got consolidated into one full-time operations coordinator. This reduced overhead while actually improving efficiency.

Fifth, I established performance metrics: patient satisfaction scores, provider utilization rates, claim processing time, customer acquisition cost. These went on a weekly dashboard so problems surfaced immediately instead of quarterly.

The Results

‍After ten months, the transformation was real. Monthly revenue climbed from $180,000 to $340,000 -an 89 percent increase - with better margins because operations were actually efficient. They reached cash flow breakeven by month eight and turned profitable by month ten.

Employee turnover, which had been trending toward 30 percent, dropped to 12 percent. Patient no-show rates fell from 22 percent to 13 percent. Satisfaction scores rose from 3.9 to 4.6 out of five.Most importantly, we built internal capability. I trained the operations coordinator on all key processes and mentored the founders on operational thinking. By month twelve, they hired a full-time operations manager who'd worked alongside me during the engagement. When I rolled off, the systems stayed in place.

A fractional COO fills that gap affordably and flexibly, bringing battle-tested expertise at a fraction of full-time cost. For this company, operational infrastructure unlocked sustainable growth while preserving founder sanity and investor capital.