Develops and/or maintains effective and efficient communication with the patient, interdisciplinary coordinated care delivery model teams, VA medical centers, and other agencies (e.g., assist with communications during the inpatient to outpatient discharge; communicate with non-VA medical facilities; prepare correspondence to notify patients of appointment details. 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.