Need to relocate but unsure about opportunities

Ok, so here's the deal.  I worked for a Big 4 firm (audit) until the year before my promotion to manager, then jumped into industry and have since worked a couple different jobs at a Fortune 200 company.  I've still got an analyst title because getting a better title here is like pulling teeth, but my experience speaks for itself.  I spent the first several years in the controller's department working on both internal accounting issues and with external reporting, then moved into a different job where I got a better look at how departments are run, budgeting, closing cycles, indirect supervision of some non-exempt employees, etc. 

Ok, that's a brief background.  Now here's the tricky part.  My wife and I are both from the same area, and we want to relocate back there to be closer to our families.  She works in healthcare and can quite literally get a job anywhere we go, so that's no big deal.  But for me, the town/small city we're moving to has fewer options.  There are a couple decent sized yet still small companies there, and my background should certainly get me at least a look in the doors  since it's not often someone with my experience would move to this area.  The thing is, there isn't much turnover because there isn't the ability to jump around between jobs and companies like there are in a bigger city.  I can't take a huge cut in pay, the cost of living isn't that different, but i could sacrifice maybe 5-8% and still pay for daycare/mortgage/cars (as long as my wife works, too). 

So here's the question for the peanut gallery.  Has anyone every made a jump similar to this and gone to a small company, for instance something like a multi-office medical practice or legal practice, and worked as their primary accounting person (call it controller/CFO/bookkeeper, whatever) and how did it go?  There is a lot more opportunity to go to this kind of practice where I'd be the main accounting person, and I could make the money I want.  So what's it like?  I naturally assume most of these places are trainwrecks, but is that really the case?  Can this be the promised land, or is it just a mirage with sand behind it?  It's not practical to move there and work where I currently am, so I have to move to a new job.  But having never worked in a small operation, I just know very little about it.  All thoughts/help/quips/and barbs are welcome.

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