They develop/maintain effective and efficient communication with the patient, interdisciplinary team, VA medical centers, and other agencies (e.g., assist with communications during the inpatient to outpatient discharge; communicate with non-VA medical facilities; facilitate/process secure messaging with the patient and team; notify patients of normal lab results; develop and manage a tracking system for follow up care such as consults, tests, etc.). Advanced knowledge of policies and procedures associated with interdisciplinary coordinated care delivery and/or care in the community operational activities that affect patient flow, and patient support care administrative functions to include, but not limited to appointment cycles, outside patient referrals, follow-up care, overbooking, provider availability, etc.