The Commission meets monthly on the fourth Thursday at 6:00pm at the New River Valley Business Center in Fairlawn. All meetings are open to the public. The Commission composition is unique in that all 12 member local governments appoint an elected official and the communities with more than 3,500 residents also appoint a citizen representative. Virginia Tech, Radford University, and New River Community College are members of the Commission and appoint a representative from their adminstrative leadership. The Commission sets policy for the organization, appoints the executive director to manage the affairs of the Commission and works to address issues of regional significance.

Each year Commission members elect officers to serve on the Executive Committee in the positions of chair, vice-chair, treasurer, and member at-large. The immediate past chair is also a member of the Executive Committee. The Executive Committee typically meets monthly to prepare for the regular Commission meeting.