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. The duties include, but are not limited to: Maintains effective and efficient communication with the patient, interdisciplinary teams, VA medical centers, and other agencies (e.g., assist with communications with non-VA medical facilities; facilitate/process secure messaging with the patient and team; develop and manage a tracking system for follow up care such as consults, test, etc.).